NUR 510 Week 2 discussion &#8211; Leadership and Role of the Advanced Practice Nurse

Hi everyone,

Sorry I had to make a table for this presentation, I though of simplifying it and simply adding up the last pieces of my thoughts outside of the table.

APN Role in New Jersey	Work Environment	Level of Accountability	Patient Population	Salary range (New Jersey)	Scope of Practice
Clinical Nurse Specialist (CNS) – CNS are advanced practice nurses that provide care utilizing evidence-based practices that promote healthcare outcomes in collaboration with other interdisciplinary staff (Darmody, 2019). -Regulated by the NJ Board of Nursing.	CNS work in hospitals, physicians offices, laboratories, outpatient care centers, colleges and universities and other clinical locations.	CNS are usually employed by institutions like hospitals and community setting, their level of accountability is minimal compared to that of the physicians, similar to the Nurse Practitioners.	Pediatrics, Adult-gerontology, home care and psychiatric patients.	The average annual salary for CNS $101,276 with the highest paid CNS earning more than $120,000. (Salary.com, 2018)	CNS, work in collaboration with physicians and other health care practitioners. According to the National Association of Clinical Nurse Specialist (NACNS), CNS provide clinical expertise, leadership, education and help in innovations in hospital, community or outpatient settings.
Nurse Practitioner (NP) – A masters’ educated nurse who has been trained and educated on how to diagnose and treat and treat diseases. Often, they are referred to as a physician’s extension. Regulation of practice varies depending on the state. NJ’s nurse practitioners have limited practice, they work in collaboration with physicians. Regulated by the Board of Nursing	Hospitals, private practices, ambulatory clinics and long-term care.	Since APN’s in NJ do not have full-practice authority and are usually employed by hospitals, physicians and other clinical institutions, the level of accountability is minimal. Between September 1990 & November 2012, only 1% of NJ’s APRN’s were reported for malpractice compared to the nearly 34% of NJ physicians (Torre & Drake, 2014).	Adult Adult-Gerontology Pediatric Women and women’s health Psychiatric patient population	The NP median salary as of 2017 according to the Bureau of Labor Statistics (BLS) is $103,880, although this amount may vary depending on the degree of specialty, the location and years of experience. (BLS, 2017)	NP’s practice in collaboration with physicians. They also have prescriptive authority but has to be in a joint protocol with physicians especially with controlled substances (Phillips, 2019).
Certified Registered Nurse Anesthesiologist (CRNA) – CRNA’s are advanced practices nurses who administer anesthesia or other medications. They also monitor patients who are recovering from anesthesia administration. Regulated by the Board of Nursing	Hospitals, ambulatory care	NJ state legislations require CRNA’s to be supervised by a physician licensed to provide anesthesia or an anesthesiologist. Hence, the “captain of the ship” doctrine applies to the same. Similar to other APRN roles (Torre & Drake, 2014).	Patients from all walks of life who are undergoing procedures requiring anesthesia.	CRNA’s are the highest paid nurses. According to the BLS report in 2016, the average salary for CRNA in NJ is $177,120 (BLS, 2016).	As earlier mentioned, CRNA’s practice under the supervision of an anesthesiologist or a physician certified to provide anesthesia in sedation procedures.
Certified Nurse Midwife (CNM) – These are nurses who are educated to provide family health services as well as family and child-bearing care (DeNisco & Barker, 2015). – Regulated by the Board of Midwifery	Hospitals, birth-centers, homes and offices.	In NJ, prior to practicing as a CMN, a consulting agreement must be entered into by the CNM and a licensed physician who holds hospital privileges in obstetrics and gynecology (NJAC, 2019).	Women & infant	According to salary.com, the average salary for NJ CNM’s is at $120,334 as of 2019.	CNM’s have prescriptive authorities in NJ. They can also perform simple diagnostic procedures like ultrasound and some gynecological examinations (NJAC, 2019).

Pros and Cons

Being a licensed APN is fulfilling, professionally, academically and financially. That would be a major pro in this category. However, one of the problems that may arise is the increase in liability in becoming an advanced practice nurse. Leadership skills will be put to test and the bigger mistakes we make may lead to bigger problems.

For CNS, the advantage will be the scope of practice and the financial fulfillment derived from it. CNS are also tasked to educate other nurses hence, the opportunity to develop plans and innovations. One major disadvantage however is the frustration that may arise from failure to implement plans and projects. Also, CNS are mostly overlooked in the hospital setting (Darmody, 2019).

For NP’s, as always, one major factor that attracts other nurses and myself towards this role is the financial reward. However, the liability becomes bigger as more patients and other professionals rely on your skill and expertise as a nurse practitioner. I personally witnessed how the NP’s at work can also suffer from exhaustion (Torre & Drake, 2014).

For CRNA’s, again, the financial gratification is a very good draw to this profession as it is also considered the highest paid nursing profession. It can also be fulfilling because the physical effort is lesser compared to that of the floor nurses and other roles. However, the level of accountability seems much higher and the education requirements seem more rigorous and time-consuming (Lamb, 2018).

For CNM’s, they are also highly paid just like all other APN roles. This is suitable for nurses who are really interested in child-birth and women’s health. However, nurses who cannot do so may not be happy being a CNM (NJAC, 2019).

Evaluation

I am currently taking the FNP program to be a nurse practitioner. I have chosen this track because it has been my dream to work in the primary care setting. Another drive was the physical exhaustion from being a bedside nurse, however, while moving further to this program, it has made me realize the great importance and the valuable contributions a nurse practitioner can give to the health care system itself. While researching and reading more about the different APN roles, I came to understand the different contributions each can give to the health care system. However, this did not change my mind from my focus on becoming a FNP.

Plan

After graduation, I plan to practice in the family practice within my community. I plan to keep learning more by keeping abreast to news and recent developments, legislative or otherwise, about the APN profession. In the long run, I would eventually love to introduce this concept to my home country where this practice is still unknown and where it is very badly needed.

Summary

These APN roles may differ in some of the roles and responsibilities but the goal is mainly for a better provision of health care to the population. In this presentation, I have discussed the different scopes, the level of accountability, the definition of each of the four APN roles, the salary, the work environment and the population each role specializes in.

References

Darmody, J. (2019). Becoming a clinical nurse specialist in the United States. Educator’s Corner 33(6), 284-286. doi: 10.1097/0000000000000480

Retrieved from: https://nacns.org/advocacy-policy/policies-affecting-cnss/scope-of-practice/ (Links to an external site.)

Retrieved from: https://www.salary.com/research/salary/benchmark/clinical-nurse-specialist-salary (Links to an external site.)

Phillips, S. (2019). 31^stAnnual APRN legislative update: Improving state practice authority and access to care. The Nurse Practitioner 1 (44), 27-55. doi: 10.1097/01.NPR.0000550248.81655.30

Retrieved from: https://www.bls.gov/oes/current/oes291151.htm (Links to an external site.)

Retrieved from: https://www.bls.gov/oes/current/oes291171.htm (Links to an external site.)

Torre, C. & Drake, S. (2014). Maximizing access to healthcare in New Jersey: The care for APN’s. New Jersey Nurseretrieved from: https:pdfs.semanticscholar.org/84e7/f7e810d75b39bea0c6217f953698334ee.pdf

DeNisco, S.M., & Barker, A. M. (2015). Advanced practice nursing: Essential knowledge for the profession(3rd ed.). Retrieved from https://bookshelf.vitalsource.com

Certified Nurse Midwife Scope of Practice. Retrieved from: https://www.njconsumeraffairs.gov/regulations/Chapter-35-Subchapter-2A-Midwifery-Liaison-Committee;.pdf (Links to an external site.)

Lamb, K. (2018). Understanding motivations and barriers of CRNAs involved in global health: A qualitative descriptive study. AANA Journal, 86(5), 371–378. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=132213421&site=eds-live&scope=site

Nov 5, 2019Nov 5, 2019 at 4:52pm

Karina, great post. So many patients are litigious these days. Do you think that some of these roles are more likely to have the risk of a lawsuit than others and if so, is the NP going to be responsible for responding to lawyers in the case or the supervising MD?

Collapse Subdiscussion Karina Takinan

Karina Takinan

Nov 6, 2019Nov 6, 2019 at 12:56pm

Professor Storms,

APN’s, whatever role they play, are at a similar risk of lawsuit with physicians (PR Newswire, 2018). In New Jersey however, due to the collaborative role that the physicians have together with the APN’s, the liability becomes more complicated. In cases where NP’s are actually employed by the physicians or a hospital institution, vicarious liability sets in and the physicians and/or the institution acquires the liability over the APN’s action (West, 2014). This can still be determined further in the court of law with the facts and other pieces of evidence which is beyond our scope in this discussion. Furthermore, in a collaborative relationship between APN’s and physicians which is not clearly defined can prove riskier for the physicians than the APN’s because of the doctrine of respondeat superior which, again, gives rise to the vicarious liability held by the physician employer or the institution (Drake & Torre, 2014). Hence, key to a harmonious relationship is a clear cut definition of roles between the APN’s and the physicians when entering into a collaborative contract or agreement.

So to answer the question on whether the APN is going to be responsible in answering the lawyers will depend on the employer-employee relationship the APN has with the physician and/or hospital.

Thank you.

Karina

Reference

PR Newswire. (2018, March 13). Study shows nurse practitioners and physicians face similar liability risks. PR Newswire US. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=n5h&AN=201803130630PR.NEWS.USPR.LA36997&site=eds-live&scope=site (Links to an external site.)

West, J. C. (2014). Case law update. Journal Of Healthcare Risk Management: The Journal Of The American Society For Healthcare Risk Management, 34(1), 45–51. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1002/jhrm.21150 (Links to an external site.)

Nov 8, 2019Nov 8, 2019 at 12:22am

Dr Storms,

If a physician is associated with an NP who is sued, the physician bears some risk of being sued as well. It is documented that a physician can be exposed to liability for malpractice when a patient is harmed by the actions or inactions of a NP, even if the physician was not directly involved in treating the patient (Paterick, Waterhouse, Paterick, & Sanbar, 2014). It is speculated that, there are several legal theories that may be applied to attach liability to a physician, either directly or vicariously, for a NP’s negligence. First, the physician may be directly responsible for negligent hiring of a NP. The screening process necessary to determine whether a NP is competent and capable of performing the specific functions that will be required includes a review of educational background, appropriate certification, prior work history and recommendations from previous employers or professors. Paterick et al, (2014) explain how the other legal ground for finding a physician directly liable for the actions of a NP is a failure to supervise properly. The starting place for determining the required level of supervision is the applicable state statute and regulations. It acknowledged that many statutes specify whether the supervising physician must be physically present in the facility where the NP is working, or can have some lesser degree of availability. The ratio of supervising physicians to NPs also may be spelled out in the statutes (Paterick, Waterhouse, Paterick, & Sanbar, 2014).

As documented by Bernard (2015), the responsibility for quality assurance, including review and cosigning of charts is also a common statutory provision. It is proven that, failure to perform any of these functions may in some instances be deemed negligence perse such that the supervising physician may be held liable even without proof of negligence by the NP. A physician may also be held vicariously liable for the acts of an NP on the grounds that the NP is acting as an agent of the physician. In some states, statutes create a conclusive presumption of agency so that a physician will always be responsible for the negligence of a NP (Paterick, Waterhouse, Paterick, & Sanbar, 2014).

In other states, liability will depend on whether the physician has a right to control the work done by the NP. However, given the typical requirements of supervision, it will be a rare circumstance when a NP will not be found to be an agent of the supervising physician. It is also important to be aware, to the extent possible, of the applicable standard of care for NPs. In some states, the NP is held to the standard of care of the supervising physician, on the theory that the NP is carrying out the function of the doctor and the patient is entitled to an equivalent level of treatment regardless of the provider (Bernard, 2015),

References

Bernard, C. D. (2015). Physician liability for the actions of midlevel providers. Medical Economics, 92(4), 43–45. Retrieved from https://search-ebscohost (Links to an external site.) com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=mdc&AN=26299005&site=eds-live&scope=site

Paterick, B. B., Waterhouse, B. E., Paterick, T. E., & Sanbar, S. S. (2014). Liability of physicians supervising nonphysician clinicians. The Journal Of Medical Practice Management: MPM, 29(5), 309–313. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=mdc&AN=24873129&site=eds-live&scope=site

Collapse Subdiscussion Christian Parker

Christian Parker

Nov 8, 2019Nov 8, 2019 at 11:27am

Dr. Storms

I have noticed over the past few years people are more likely to sue you than the previous norm. Is this because the millennial generation mentally of financial reward. “The consumer is the king. He has the right to know what he is receiving” (Karri, 2018). With becoming a provider this is very scary, though on the flip side it will help make sure I am doing everything right. It is very important that the consumer is aware of every detail, also that the documentation is excellent. We also need to respect our patients wishes for their care. If as a nurse practitioner we do not feel comfortable about anything we should consult the doctor before given any care.

Reference:

Karri, R. (2018). “PUT A SIGN HERE and PUT A SIGN THERE!” (obtaining informed consent is not so easy in this changed litigious world). Archives of Mental Health, 19(2), 52. doi: 10.4103/amh.amh_42_18

Collapse Subdiscussion Kimberly Logsdon

Kimberly Logsdon

Nov 8, 2019Nov 8, 2019 at 7:46pm

Professor Storms,

Thank you for posing the question of if some of these roles are more likely to have the risk of a lawsuit than others. The answer is that it varies by state. If the litigation occurs in a state that requires nurse practitioners to work under a physician or collaborate with a physician, then the physician may be responsible for responding to the lawyers. If the litigation occurs in a state that grants nurse practitioners full independent practice authority, then only the NP is liable. In researching the answer to your question, I also learned about group medical malpractice insurance policies. Employers and unions inform NPs that they are covered, giving them a false sense of security. It’s what’s omitted that can be dangerous. Employers often carry “claims made” rather than “occurrence” policies. This means the nurse practitioner will not be covered for an incident that occurred while employed once he or she leaves that job. Occurrence policies cover the nurse practitioner up to the day he or she stops practicing (Gardenier, 2014).

Kim Logsdon

References

Gardenier, D. (2014). Should nurse practitioners who are covered by large group malpractice plans also maintain their own malpractice coverage? The Journal For Nurse Practitioners. doi:https://doi.org/10.1016/j.nurpra.2014.07.024

Collapse Subdiscussion Nicole Truslow

Nicole Truslow

Nov 9, 2019Nov 9, 2019 at 8:34pm

Professor Storms,

I believe any of these roles are at risk of lawsuits. People will sue for any reason without much cause behind it. I think the lawsuits that could hold the most detrimental reasons would be against nurse midwifes. When dealing with delivering babies, typically if something goes wrong it is a major problem. Not only are mothers at risk but so is the unborn baby. Even when advanced practices nurses are working under a physician’s license they themselves are still liable and at risk. Typically when a person sues they sue everyone that has been involved in the case. I hold a certification in nurse life care planning and work with attorney’s on different medical cases and find that in most cases everyone is dragged into it no matter who small a part they had in providing care. This is unfortunate for medical providers because in general there is not malicious intent to ever do harm to any patients and some people are just looking for a payout.

Nicole Truslow

Collapse Subdiscussion Christian Parker

Christian Parker

Nov 7, 2019Nov 7, 2019 at 10:22am

Karina

The interesting thing about New Jersey that I saw was the pay difference between New Jersey and North Carolina. I would think that New Jersey would pay more than North Carolina for nurse practitioners. “Compensation for nurses decreased 3.1% from 2015 to 2016, for an average salary of $61,875, according to survey information collected from nearly 20,000 health care workers and reported in the Health eCareers 2016 Salary Guide. NP compensation, however, increased 5.3%, for an average salary of $100,549″ (Zolot, 2016). I appreciate that NP compensation is rising, but the sad truth about Registered nurse salary is decreasing. Working as certified nursing assistant then a registered nurse, I have saw how important both jobs are. I also know during my career as a nurse practitioner when it comes to my patient, I need to trust the RN and their skills. Because majority of the time the RN notices changes/concerns for the patient before the provider.

Reference:

Zolot, J. (2016). Salaries for Nurses Decrease, While NP Salaries Rise. AJN, American Journal of Nursing, 116(11), 16. doi: 10.1097/01.naj.0000505573.04645.f5

Collapse Subdiscussion Navdeep Kaur

Navdeep Kaur

Nov 4, 2019Nov 4, 2019 at 10:10pm

Hello Professor and Class,

The four types of advanced practice nurses in California are Nurse Practitioners, Nurse midwives, Nurse anesthetists, and clinical nurse specialists. The nurse practitioners work environment is primary care. They cannot practice alone in the state of California and must follow policies and protocols set by a supervising physical. The patient population for a nurse practitioner is anyone cradle to grave needing acute or chronic care. According to salary.com the average salary for a NP in California is $105,920. The scope of practice is a registered nurse who has additional training through a program that conforms to board standards, who can treat chronic and acute illnesses (California Scope of Practice Policy, 2019). Work environment, level of accountability, patient population, salary and scope of practice. In the future I would like to work as a nurse practitioner and a pro to this is I get to work in a primary care setting taking care of all different types of patients. A con to this is in the state of California I cannot work as a solo practitioner and will have to work under a physician. The quality of care is the same when Nurse practitioners are delivering it as physicians if not better (Mark & Patel, 2019) so it does not make sense why they do not have independence.

The nurse midwife works in an OBGYN office, antepartum, intrapartum, postpartum, interconceptional periods and with family planning needs. Their level of accountability is the same as a nurse practitioner, they report to a supervisor or manager such as an MD. The patient population that a nurse midwife works with is women or transgenders that are in need of obstetric or gynecologic needs. The average salary according to salary.com is $122,300. The scope of practice is to provide necessary supervision, care, advice to women or transgenders during antepartum, intrapartum, postpartum, interconceptional periods and with family planning needs (2016). A pro to this line of work for me would be working with women of childbearing ages. I am used to that population group and it would be an easy transition for me. A con would be the hours of work, being on call all the time and as a nurse midwife the doctor you work for will probably have you on night call a lot.

Nurse anesthetists work in hospitals, surgical centers and offices. They are independent practitioners who are legally responsible for their own actions and due to this their salary is higher than the other advanced practice nurses (2009). They are highly trained specialists who make on average $204,547 annually. Their scope of practice includes assessing, implementing plans and performing general, regional and local anesthesia. A pro for this line of work would be the amount of independence and money you make. But the amount of independence and legal obligation can be a con as well.

A clinical nurse specialist depending on specialty can work with certain populations, in certain settings such as ER, disease or medical subspecialty, type of care such as rehabilitation or psychiatric or type of problem such as pain or wound (2018). Level of accountability is the same as a np and nurse midwife. Patient population can be direct or indirect patient care activities. The average salary according to salary.com is $117,574. The scope of practice includes patients, nursing personnel and organization systems, providing research, education, consultation, clinical practice and clinical leadership. A pro to this job is having flexibility and being able to do a variety of different tasks. A con may be figuring out where you want to work and what you want to do with this advanced practice degree, it seems so broad that I may have a hard time figuring out what I want to do.

I currently would like to become a family nurse practitioner. And as a FNP I have the flexibility to work with a variety of different populations. I moved from Virginia to California so there are more restrictions for me in this state but that is ok because I still see myself as a FNP and not pursuing any other advanced practice degree. My plans have changed a little bit since moving to California. I originally had planned to work with one of the doctors I work with after I graduate but things change so here I am. I would like to get a job in a family practice near my current home. My idea has not changed after doing some extra research but I’m glad this discussion got me thinking about next steps and what I will be able to do in my current state.

Reference

Advanced Practice and PHN Certification. (2018, March 29). Retrieved from https://www.rn.ca.gov/applicants/ad-pract.shtml (Links to an external site.).

California association of Nurse anesthetists CRNA scope of practice guidelines. (2009, September 21). Retrieved from http://canainc.org/compendium/pdfs/CRNA Scope of Practice.pdf.

Certified Nurse-Midwife practice explanation of standardized procedure for CNM. (2016, November 16). Retrieved from https://www.rn.ca.gov/pdfs/regulations/npr-b-32.pdf (Links to an external site.).

Mark, B., & Patel, E. (2019). Nurse practitioner scope of practice: What do we know and where do we go? Western Journal of Nursing Research, 41(4), 483-487. doi:10.1177/0193945918820338

Nov 5, 2019Nov 5, 2019 at 4:53pm

Nav, something I find interesting is the reimbursement rates across the roles. For example, CNMs get reimbursed 100% for services billed whereas NPs only get 80%. How do you feel about this?

Collapse Subdiscussion Navdeep Kaur

Navdeep Kaur

Nov 6, 2019Nov 6, 2019 at 7:20pm

Hello Dr. Storms,

Wow I actually did not realize that was the case. So I did some research and according to the American College of Nurse-Midwives the reimbursement rate increased from 65% to 100% in 2010 due to a law that President Barack Obama signed. The article states that CNM’s wrote called and emailed their members of Congress to support this reimbursement. It is definitely well earned due to the amount of hours that they work and the hard shifts. I have seen my friends miss out on so many events such as birthdays, holidays and so many other events. As a future nurse practitioner I too am going to follow in The CNM’s direction and write to my congress to see if they can support us. I could be bitter and say why aren’t we getting the same reimbursement, but it seems like a lot of work went into this and we should follow in their direction.

Reference

Equitable medicare reimbursement. (2011). Retrieved from https://www.midwife.org/Equitable-Reimbursement

Collapse Subdiscussion Karina Takinan

Karina Takinan

Nov 7, 2019Nov 7, 2019 at 11:06am

Hi Navdeep and Professor Storms,

Indeed, there still seems to be an inequality regarding the reimbursement rates between NP’s and physicians in primary care despite the similarity of the care being provided. Across the US, NP’s CRNA’s and CNS have 85% reimbursement rates while Oregon is the only state that requires private insurers to reimburse NP’s and PA’s in primary and behavioral healthcare at 100% rate (Gill, 2019). There is now a call statewide for NP’s to take action regarding this matter to ensure that reimbursement methods be fair and competitive (AANP, 2017). As future FNP’s it is important that we are aware of these current issues that surrounds the profession that we are going into and to be able to contribute as much as we can to help grow nurse practitioneering.

Karina

References

Gill, J. (2019). Same pay for the same service: Advocacy efforts in the northwest. The Nurse Practitioner 44(6), 9-11. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=edb&AN=136493607&site=eds-live&scope=site (Links to an external site.)

AANP Forum (2017). The Journal for Nurse Practitioners. Retrieved from https://doi-org.chamberlainuniversity.idm.oclc.org/10.1016/j.nurpra.2017.01.008 (Links to an external site.)

Collapse Subdiscussion Rosie Shelton

Rosie Shelton

Nov 5, 2019Nov 5, 2019 at 10:14am

Professor Storms and class,

Part of my assignment is located as an attachment because it is on a table grid and if I copy and pasted it, it was not configured right. The numbers located in my references correlates to the information located on my attachment. Thank you.

PROS

CNP-Variety of work place settings *salary is competitive *work independently *Close to the traditional idea of a nurse *Education and training is reasonable *Proficient at many tasks like medical doctors *level of autonomy

CNS- *Interesting and Diverse job *Can become leaders within hospitals health systems & organizations *Impacts at a wider population level as opposed to individual patients level *Considered clinical experts.

CRNA- *Nurse Anesthetist requires an encyclopedic level of knowledge of the human body, anesthetics and the effects on the patient. *Collaboration with an entire medical team *Out of the four, salary is the greatest for CRNA’s *Autonomy

CNM-*Specialized training *work directly with mothers-to-be throughout the gestation cycle *Offer a holistic approach.

CONS

CNP- *In California they need physician supervision for furnishing prescriptions and controlled substances *with the shortage of physicians, CNPs are exposed to burnout

CNS- *More focused on population/community broad based illnesses, and treating the population. *Least competitive salary scale.

CRNA-*Requires intense studying curriculum, and hundreds of clinical hours of work (not for me) *Responsibility level *Competitive field

CNM- *Midwives carry only basic tools (no US or anesthesia) *Not qualified to manage high-risk pregnancies *cannot perform cesareans *Specialized/limited area of study.

My rational for choosing the CNP route is that I love the idea of the close relationship it is to nursing. NP practice compared to the other three offers a wide variety practice settings to choose from and the salary scale is very competitive. The job outlook appears to be flourishing and the NP profession will continue to grow which ensures job security for my future. My plans after graduation is to initially work in a patient care setting such as a local clinic so that I gain the experience in managing medications, illnesses; treatment plans and develop partnerships with patients. After about a year or so in the clinical setting, I plan on applying to the emergency department to work in the triage area. This is where I think I would feel the most comfortable (ER), as most of my years of nursing have been spent in ER. I love everything about the ER and I feel this is where I belong. I see a lot of patients who lack education about their medical illness and I can make an impact with these patients by giving them the knowledge to manage their illnesses at home by empowering them to take control. Education needs to start here in the ER so that when patients leave they are not back the next day wondering why they don’t feel any better.

My idea of the NP has not changed a bit, I do not mind at all that NP’s require a physician’s oversight and actually I even feel that maybe this is a great idea. There are a lot of great benefits in becoming an NP, I just hope that after all this schooling and clinical hours I will be investing in that I would love it more than just the thought of it. The autonomy and freedom associated with the NP status is something I am looking for in my future career.

References

(1) American Association of Nurse Practitioners. (2015). NP Fact Sheet. Retrieved from https://www.aanp.org/images/documents/about-nps/npfacts.pdf (Links to an external site.)

(2) Foster, J., Flanders, S., (2014) “Challenges in CNS Practice and Education” OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 1. doi: 10.3912/OJIN.Vol19No02Man01

(3) Malina, D., Izlar, J., (2014) “Education and Practice Barriers for CRNAs” OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 3. doi: 10.3912/OJIN.Vol19No02Man03

(4) Salary.com CNP, CNS, CRNA, CNM

(5) Walker, D., Lannen, B., Rossie, D., (2014) “Midwifery Practice and Education: Current Challenges and Opportunities” OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 4. doi: 10.3912/OJIN.Vol19No02Man04

NR510APN.docx

Nov 5, 2019Nov 5, 2019 at 4:53pm

Good, Rosie. Let’s consider family life. Assuming a potential MSN student has 2 small children at home, how do you think each role would effect her decision on the best fitting role for herself?

Collapse Subdiscussion Rosie Shelton

Rosie Shelton

Nov 7, 2019Nov 7, 2019 at 8:57pm

Professor Storms,

Great question! I recently had a fellow nurse friend who just finished a CRNA program and all I can say, is this is not the program of choice if one has two small children at home. The only way he was able to make it and finish was because his wife who was also a fellow nurse made the decision to move in with her mother. They have 3 young boys but more like 11, 9, and a 6 year old, a big lavish house, two nice expensive vehicles and a boat, but they had to end up making certain decisions and sacrifices to make this happen. They downsized to one vehicle, sold their boat and house and he had to quit his job at the hospital and move out of state where his program was located (I think it was in Iowa). I am not completely sure of all the other details like loans or finances, but what I do know is that this particular program is intense, and I would say it is not the best choice for your scenario. The other three (CNP, CNS, and CNM) generally take anywhere from two-three years in a MSN program, now that’s after you have your RN and your BSN. So I would say that any one of the three just mentioned would be a more reasonable choice. It all depends on where you are in your nursing career, what kind of support system you have, and basically it’s a person choice. If you want any one of these careers bad enough, you will do what you got to do. Although the last three programs just mentioned are all very similar in the amount of time it takes to complete a MSN program, for the scenario you mentioned above, I would have to go with an online CNP program (I’m a little biased). CNP, CNS, CNM all have similarities in work environment, level of accountability, patient population, salary, and scope of practice to an extent, except CNM is more focused on the mother baby aspect.

Thank you for the conversation. *Rosie

Collapse Subdiscussion Kenneth Steier

Kenneth Steier

Nov 7, 2019Nov 7, 2019 at 10:44pm

Hello Dr. Storms,

“On average, salary for a full-time NP (working 35+ hours per week) was $105,903 annually and the average hourly rate, regardless of hours worked, was $60.02” (Nurse Practitioner Role Grows to More Than 270,000, 2019). The Nurse Practitioner position seems to be the APN position that would be most suitable for having a family of four (4), including two (2) adults and two (2) children. NPs have the option of being able to have a more consistent schedule that would allow for the provider to get home after work and have a family life.

On the other hand, the other three (3) APN roles (Nurse Anesthetist, Nurse Specialist and Nurse Midwife) all are more likely to have a more hectic and random schedule. Nurse Anesthetists work in many different settings and there is always the chance that they may get called in, if a surgery needs to be done in an emergency and they can also have long hours that they are working. Nurse Specialists like NPs can have a more consistent schedule, but they are normally employed in larger hospitals and at times can include working nights or longer hours during the week. Nurse Midwives can be called in at any time if they have visiting rights at the hospital or if they have their office in house or at an office building. When Nurse Midwives have a large group of pregnant clients, they can get called at all hours of the night to come into the hospital/office and can make for very long nights.

In closing NP’s have the position that would be best for a family life. NP’s can have a consistent schedule and stick to it. All the other positions have schedules that can vary. At times the APN positions other than NP positions can have emergencies that won’t allow the person to be able to have a family life.

References

Nurse Practitioner Role Grows to More Than 270,000. (2019, January 28). Retrieved from https://www.aanp.org/news-feed/nurse-practitioner-role-continues-to-grow-to-meet-primary-care-provider-shortages-and-patient-demands

Collapse Subdiscussion Nicole Truslow

Nicole Truslow

Nov 10, 2019Nov 10, 2019 at 7:39pm

Kenneth,

I agree with your post as far as NP’s and a more consistent schedule. This is one of the very reasons this is the route I have also chosen. I have 3 children, 1 that happens to just be a year old, and I need to have consistency with my schedule and I don’t want to be on call and having to run out at all hours of the night. The other roles, at least in the state I reside, do make a considerable amount more financially but to me that would not make up for the time taken away from my family. I want to be able to take care of my patients and take care of my children and the NP role can give me the best of both worlds.

Nicole Truslow

Collapse Subdiscussion Katy Claus

Katy Claus

Nov 8, 2019Nov 8, 2019 at 12:17am

Rosie,

I could not agree more with your pros of becoming a CNP over the other three APRN options. CNPs have the opportunity to work in virtually any form of healthcare form kids to geriatrics. I personally like that you are able to specialize. For example, I intend to focus my CNP career on cardiac health in my community. Of course the salary is not as great as that of a CRNA, but there are just as many pros and cons in that position. I personally think that the schooling required for becoming a CNP is much more appealing, especially for those with families and full-time jobs. For example, I originally thought I wanted to become a CRNA. However, after doing my research I realized that the schooling would not be conducive to my current life, as I work full-time. I agree as well that the autonomy as a CNP is phenomenal. Although every state is not yet a full-practice state, the one in which I live is. I believe most will soon follow, given all of the lobbying for nurse practitioners. Finally, I love that you stated that this APRN position is most like a traditional nurse. After all, we all became nurses to advocate and help those in need, regardless of the position. Therefore, I believe becoming a CNP will be the best opportunity to reach people in a more personal manner. Personally, I am less interested in management, research, and education than I am working face-to-face with patients. Like you, I am incredibly excited to continue on this journey towards becoming a CNP! Great post! I look forward to seeing more from you!

Katy Claus

Collapse Subdiscussion Rosie Shelton

Rosie Shelton

Nov 9, 2019Nov 9, 2019 at 9:38pm

Thank you Katy,

I too feel this is the best choice for me. I basically have no interest in mother baby duties, or social work duties on a population level, and although anesthesia job duties do interest me, the determining factor was the schooling involved and my age (LOL). I feel that if I were to have chosen anything other than FNP, it would have been CRNA as well, but since I am the “breadwinner” in my family; this choice was not an option. I am very happy as well to be in this program and feel that this option is the best fit for my family and me. I only wish I would have decided to take this route 10 years ago, but I do believe everything happens for a reason. I have had fellow nurses go through the FNP program and are now practicing on their own. What they have mentioned to me is that when you are done, you can basically choose your place of employment that best fits your needs. You can practice in the ER, in a clinic specialized or not, as an “admitting” FNP in hospitals, in surgery, and so many more choices. The need is there and physicians are looking for FNP’s to assist them in their practices or in your own practice. The workforce for FNP’s has endless opportunities and therefore, will allow us to write our own ticket. What more can we ask for, we can still continue to do what we love, which is to be involved in patient care, but at a different level, it is a win win situation.

As you mentioned, every state is not yet full-practice state, this does not bother me at all, I still feel we have plenty of autonomy and I actually do not mind that a Physician is required for supervision regarding prescription medications, but I do believe one day that this too will be a thing of the past.

Thank you for the conversation,

Rosie Shelton

Collapse Subdiscussion Shaniya Tripp

Shaniya Tripp

Nov 5, 2019Nov 5, 2019 at 7:35pm

Dr. Storms and class,

The Advance-Practice Registered Nurse (APRN) role can by filled as a Certified Nurse Practitioner (CNP), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), or Certified Registered Nurse Anesthetist (CRNA). One article helps to describe the roles that can be filled and states, “Advanced Practice Registered Nurse specialty education and practice build upon and are in addition to the education and practice of the APRN role and population focus, e.g, a Certified Registered Nurse Anesthetist (CRNA) could specialize in pain management; a Certified Nurse-Midwife (CNM) could specialize in the care of postmenopausal women, a Clinical Nurse Specialist (CNS) could specialize in palliative care, or, the Nurse Practitioner (NP) could specialize in Hematology-Oncology” (Hoebelheinrich, 2018). In the state of Connecticut the APRN roles are as follows:

Certified Nurse Practitioner (CNP)

Scope of Practice: “This APRN performs acts of diagnosis, and treatment of alterations in health status and must collaborate with a Connecticut-licensed physician. In all settings, the APRN may, in collaboration with a licensed physician, prescribe, dispense, and administer medical therapeutics and corrective measures and may request, sign for, receive, and dispense drug samples” (Kasprak, 2009).

Work Environment/Patient Population: “Nurse practitioners (NPs) are health care providers who practice in a variety of settings such as acute care, outpatient care and specialty clinics. Sometimes they serve in leadership, management, research or teaching roles within healthcare organizations or universities. NPs have undergone advanced academic and clinical training to provide medical care for a wide variety of patients. Their daily practice closely resembles that of a doctor; many NPs serve as primary care providers to adults, children and families. Others specialize in a particular area of medicine, such as psychiatry or dermatology” (Painter, 2018).

Level of Accountability: “Any NP who elects to practice without a collaborative agreement shall maintain documentation of having engaged in the performance of advanced practice level nursing activities in collaboration with a Connecticut licensed physician for a period of not less than three (3) years and not less than two thousand (2,000) hours” (DPH, 2019). Therefore, in CT, an NP must work under a Physician for no less than three years. They have a collaborative agreement that specifically outlines what the NP will be held accountable for. “The collaboration shall address a reasonable and appropriate level of consultation and referral, coverage for the patient in the absence of such APRN, a method to review patient outcomes and a method of disclosure of the relationship to the patient” (DPH, 2019).

Salary: “The average Nurse Practitioner salary in Connecticut is $116,693 as of October 30, 2019, but the range typically falls between $108,281 and $126,765. Salary ranges can vary widely depending on the city and many other important factors, including education, certifications, additional skills, the number of years you have spent in your profession” (“Nurse Practitioner”, 2019).

Pros: Autonomy after three years, Ability to open up own practice, Recognized as Primary Care Provider (PCP)

Cons: Autonomy limited in hospital settings

Certified Registered Nurse Anesthetist (CRNA)

Scope of Practice: “A licensed CRNA in CT maintaining current certification from the American Association of Nurse Anesthetists who is prescribing and administering medical therapeutics during surgery may only do so if the physician who is medically directing the prescriptive activity is physically present in the setting where the surgery is taking place” (Kasprak, 2009).

Work Environment/Patient Population: “CRNAS work in just about every medical or healthcare facility where anesthesia is administered, including surgical units, hospitals, obstetrical delivery rooms, physicians’ clinics, dental offices, pain management clinics, veterans’ hospitals, cosmetic surgery centers, military hospitals, etc.” (“CRNA”, 2019).

Level of Accountability: “Nurse anesthetists provide anesthetics to patients in collaboration with surgeons, anesthesiologists, dentists, podiatrists and other qualified health care professionals. As advanced practice registered nurses, they are given a high degree of autonomy” (“Nurse Anesthetist”, 2019). In CT however, a CRNA is not allowed to practice independently without physician supervision. Must complete 2 years in the ICU before applying to CRNA Program in CT.

Salary: “The average Certified Nurse Anesthetist salary in Connecticut is $198,496 as of October 30, 2019, but the range typically falls between $182,422 and $216,539. Salary ranges can vary widely depending on the city and many other important factors, including education, certifications, additional skills, the number of years you have spent in your profession” (“Certified Nurse Anesthetist”, 2019).

Pros: Highly respected field, ICU experience required (2 years), highest compensation

Cons: Autonomy is limited in CT; must work under Physician, must work part-time during schooling for CRNA, high stress, must have strong background in chemistry

Clinical Nurse Specialist (CNS)

Scope of Practice: “A clinical nurse specialist (CNS) is a graduate-level registered nurse who is certified in a specialty of choice” (“Clinical Nurse Specialist”, 2019). This APRN obtains a specialty certification demonstrating an advanced level of knowledge as well as advanced clinical skills in a specific area of nursing. The scope of practice differs from an NP in that a CNS usually focuses on education, research, and consulting.

Level of Accountability: A CNS in CT can prescribe medications independently if they apply for authority to do so, but this is not always required in their practice.

Work Environment/Patient Population: “Clinical nurse specialists serve as mentors, educators, and advocates. They demonstrate expertise in their specialty area and maintain strong clinical skills. As leaders, they can also promote and facilitate change. They utilize evidence-based practice to educate other nurses and to assist in developing cost-saving strategies in the delivery of care. They can also bring their observations and experience in patient care and apply it to research, policies, and to improve practices. They practice in both inpatient and outpatient populations in CT. However, there is a high prevalence of CNS’s in the hospital settings.

Salary: “The average Clinical Nurse Specialist salary in Connecticut is $114,094 as of October 30, 2019, but the range typically falls between $103,158 and $124,977” (CNS, 2019).

Pros: Expert in specialty, nurse educators on hospital units are a fantastic resource

Cons: Autonomy is limited, ability to prescribe medications vary by state

Certified Nurse Midwife (CNM)

Scope of Practice: “Nurse-midwives manage women’s health care needs, particularly family planning, gynecology, pregnancy, childbirth, and post-partum care of mothers and newborns. They must do this within a health care system and have clinical relationships with OB-GYNs that provide for consultation, collaborative management, or referral, as indicated by the patient’s health status. The CT law requires each nurse-midwife to provide (1) care consistent with ACNM standards and (2) information about, or referral to, other providers or services, if the patient asks or requires care not within the nurse-midwife’s scope of practice” (Dube & Cohen, 2013).

Level of Accountability: “ In CT, a licensed nurse-midwife, in good faith and in the course of her practice, may prescribe, dispense, and administer Schedule II, III, IV, and V controlled substances. These controlled substances may also be administered by RNs or LPNs under the nurse-midwife’s direction and supervision” (Dube & Cohen, 2013).

Work Environment/ Patient Population: Gynecology, pregnancy, childbirth, and post-partum care of mothers and newborns. Must practice, within a healthcare system.

Salary: “The average Certified Nurse Midwife salary in Connecticut is $117,766 as of October 30, 2019, but the range typically falls between $108,286 and $133,448 (“Certified Nurse Midwife”, 2019).

Pros: Family Planning specialty, experts on childbirth, great resource in OBGYN settings

Cons: Autonomy limited in CT, must work within a healthcare system

I have chosen the CNP role out of all three roles due to my current experience with liver and kidney disease and transplant. Due to my experience with caring for post-operative kidney patients, I have chosen to further my studies in efforts to focus on preventive care. An article by Simmons University, states that the role of a NP is to prevent illness and disease. It also explains that their duty can also extend beyond the exam room into the community, where they play a valuable part in health promotion, education, and advocacy (Simmons, 2016). My goal as a future CNP is to provide these services, in order to prevent the escalation of complex disease processes. Seeing first hand what these disease processes do to patients and families, has pushed me into a field that is focused on preventative care.

After graduation, it is my hope to stay within the Transplant field as I have learned that I must work under a Physician for three years in this state. Having not known this before, this has helped me to better plan out my goals post graduation. I would like to become a Transplant Nurse Practitioner who works in the outpatient setting. In my hospital setting there are NP’s that are designated to either the pre- or post-transplant population. I would like to focus on the pre-transplant population to provide education but also gather information on what led to the end stage renal disease (ESRD) or end stage liver disease (ESLD). This data will help me eventually transition to a family nurse practitioner (FNP) setting where I can focus my efforts on preventative care. Overall, while my idea of NP practice has not changed after researching the state of CT, it has helped me in decided on a plan post graduation. I learned a great deal about each and every APRN role, and did not realize how much the scope of practice differs depending on the title. I look forward to reading about just how much the roles differ from state to state.

Shaniya

References

Certified Nurse Anesthetist Salary in Connecticut (2019). Retrieved November 4 2019 , from https://www.salary.com/research/salary/benchmark/certified-nurse-anesthetist-crna-salary/ct

Certified nurse midwife salary in Connecticut. (2019). Retrieved November 4 2019, from https://www.salary.com/research/salary/benchmark/certified-nurse-midwife-salary/ct

Certified registered nurse anesthetist (CRNA). (2019). Retrieved November 4 2019, from http://www.careerprofiles.info/nurse-anesthetist.html

Dube, N., & Cohen, R. (2013). Regulation of nurse midwives in Connecticut. Retrieved from https://www.cga.ct.gov/2013/rpt/2013-R-0149.htm

Hoebelheinrich, K. (2018, April). Many lanes of APRN roles and populations. Missouri State Board of Nursing Newsletter, 20(1), 4. Retrieved from https://eds-b-ebscohost-com.chamberlainuniversity.idm.oclc.org/

Kasprak, J. (2009). Nurse practitioners (APRNS). Retrieved from https://www.cga.ct.gov/2009/rpt/2009-R-0301.htm

Nurse anesthetist. (2019). Retrieved November 4 2019, from https://explorehealthcareers.org/career/nursing/nurse-anesthetist/

Nurse practitioner salary in Connecticut. (2019). Retrieved November 4 2019, from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/ct

Painter, A. (2018). What does a nurse practitioner do? Retrieved from https://www.innerbody.com/careers-in-health/how-to-become-a-nurse-practitioner.html

Practice without a collaborative agreement. (2019). Retrieved October 28, 2019, from https://portal.ct.gov/DPH/Practitioner-Licensing–Investigations/APRN/APRN-Practice

Preventive health care: The role of Nurse Practitioners. (2016). Retrieved from https://onlinenursing.simmons.edu/nursing-blog/role-of-nurse-practitioners-in-preventive-health/

Nov 8, 2019Nov 8, 2019 at 7:46am

Good, Shaniya. One of the things that interested me in nursing was that the profession offered so many opportunities for growth. Even after starting nursing school, I was still learning of the many paths that we can take. Though some states currently restrict the practices of nurse practitioners (NPs), there are a few that recognize do their training and education. It is for this reason that we must do everything we can during our education to ensure that when we are out there providing healthcare services, we do so to the best of our abilities. According to Hart & Bowen (2016), though NPs have been shown to be successful and competent providers of care, preparedness for practice is a critical issue facing many new grad practitioners. Mentorship coupled with training has shown useful in transitioning the new role of nurses. We need to do everything we can to be as prepared as possible for our patients, improve satisfaction, and reduce cost. This starts by becoming familiar with our role and knowing that it is the road we want to take, rather than going with a different role, whether it be CNS, CRNA, CNP, or CNM

Collapse Subdiscussion Shaniya Tripp

Shaniya Tripp

Nov 9, 2019Nov 9, 2019 at 2:45pm

Dr. Storms,

After reviewing the laws and scope of practice of various states, I must agree with the states that require Clinical Nurse Practitioners (CNP’s) to work under/in collaboration with a Physician for a period of time before practicing independently. I agree that mentorship and training would be beneficial for the transition of a new graduate practitioner. Just like a new graduate nurse having a period of time on orientation, it makes sense that the increased level of responsibility of a practitioner would require a longer period of mentorship. In looking at the Primary Care setting, one article explored the barriers and facilitators to the implementation of the advanced practice registered nurse (APRN). The study found that “Facilitators included supervision and leadership” (Torrens et el., 2019). Based on its findings it concluded that, “Building collaborative relationships with other healthcare professionals and negotiating the role are critical to the success of the implementation of the advanced nurse practitioner role. Team consensus about the role and how it integrates into the wider team is also essential” (Torrens et el., 2019). Having APRN’s step into the role as Primary Care Provider’s is truly beneficial for accessibility to health care, but as you mentioned, we must first become familiar with our role, and based on research this can be done through a designated time of mentorship and collaboration.

Shaniya

References

Torrens, C., Campbell, P., Hoskins, G., Strachan, H., Wells, M., Cunningham, M., … Maxwell, M. (2019, September 27). Barriers and facilitators to the implementation of the advanced nurse practitioner role in primary care settings: A scoping review. International Journal of Nursing Studies. http://dx.doi.org/10.1016/j.ijnurstu.2019.103443

Collapse Subdiscussion Christian Parker

Christian Parker

Nov 6, 2019Nov 6, 2019 at 8:43am

Dr. Storms and Class

The four roles of Advanced Practice Registered Nurse are Nurse practitioners (NP), Certified Nurse Midwife (CNM), Clinical Nurse Specialist, and Certified Registered Nurse Anesthetist (CRNA). “The Future of Nursing: Leading Change, Advancing Health observes that the changing landscape of health care and the changing profile of the U.S. population will require fundamental shifts in the care delivery system” (Peterson, 2017). The NP can work in many different types of facilities such as primary care, acute care, psychiatry, plastic surgery and other specialty areas. When a nurse practitioner works in North Carolina in the different work environments they must be associated with a medical doctor. The medical doctor’s job is to classify medications, procedures and procedure consults the NP can do. North Carolina is a restricted states which limits the way the nurse practitioner is viewed and what level of accountability they have. This can cause the NP to have to consult others to get help for their patients or jump through hoops to get care. The NP will see a variety of ages and different areas of North Carolina that include urban or rural. Starting salary can range from 95,000 to 140000 depending on the area of North Carolina. The CNM will mainly work in practices, hospitals, health department, birthing centers, and home births. The age population is catered to women of child bearing age. The CNM also has to have a medical doctor associated with them. The salary for CNM starts out at 95,000 to 110,000. There are many areas in North Carolina that midwives cannot work in due to the area does not have an OB/GYN. They will also sign a Midwife practice agreement. When talking about Clinical Nurse specialist the important thing to talk about is the difference between CNS and NP. NP can practice autonomously and collaboratively with other health care providers. The CNS often work with other providers, less autonomy, they usually work closely with staff to educate and support through evidence based research. They can also work with many different settings and age populations. They help patients with complex medical needs with improving their health. They are big on advocating for the patient’s. The salary is a lot lower than any other advanced practice nurse which is 62,000-70,000. The last of the four roles for advanced practice nurse is CRNA. The CRNA performs pre-anesthesia assessment, administers pre-anesthetic medications, and tracheal intubates patient. All procedures must be done under an anesthesiologist although the anesthesiologist does not stay in the room to monitor the patient that is the CRNA job. Their salary ranges from 160,000 to 180,000. The pros to a Nurse Practitioner is “the advanced clinical practitioner (ACP) facilitates a holistic approach to physical and mental health” (Hutchinson, 2019, p. 147). The cons in North Carolina is that the NP is restricted to what and how they can practice. The pros of midwifery is “Midwifery is an ancient profession still actively practiced throughout the world” (Albarran & Rosser, 2014, p.949). The cons are “midwives that are not nurse-midwives are illegal in 10 states, 12 states have no laws or regulations about non-nurse-midwives, and 2 states prohibit CNMs from doing home births” (Albarran & Rosser, 2014, p.951). The pros of CNS “evidence‐based practice (EBP) in the clinical setting is recognized as an approach that leads to improved patient outcomes” (Malik, McKenna, & Plummer, 2014, p.46). The cons is where they can work, who will hire them, and their limited practice ability. The pros are “The pay is attractive, they are the highest paid advanced nurses” (Neft, 2015, p.30). The cons are “the positiona comes with great responsibily” (Neft, 2015, p.30). The reason I chose Nurse practitioner is due to my compassion for Psychiatric patients. I want to give them the treatment they deserve and help them become successful in their disease. I feel as a NP I will be able to reach them the most and there are limited providers in this area. I want to work in the emergency room setting for psychiatry. I want to see the patients when they are having their acute episodes. After working in the ER as a nurse, I was able to interact with them, and help them succeed while in the ER.

Reference:

Albarran, J. W., & Rosser, E. A. (2014). The challenges facing midwifery educators in sustaining a future education workforce. Midwifery, 30(8), 949–955. doi: 10.1016/j.midw.2013.07.016

Hutchinson, M. (2019). The Advanced Clinical Nurse Practitioner and Direct Care. Advanced Practice in Healthcare, 147–157. doi: 10.1002/9781119439165.ch10

Malik, G., Mckenna, L., & Plummer, V. (2014). Perceived knowledge, skills, attitude and contextual factors affecting evidence-based practice among nurse educators, clinical coaches and nurse specialists. International Journal of Nursing Practice, 21, 46–57. doi: 10.1111/ijn.12366

Mary E. Peterson, Ms, Aprn, Aocnp. (2017). Barriers to Practice and the Impact on Health Care: A Nurse Practitioner Focus. Journal of the Advanced Practitioner in Oncology, 8(1). doi: 10.6004/jadpro.2017.8.1.6

Neft, M. W. (2015). Anesthesia advances in ASCs. OR Nurse, 9(5), 30–36. doi: 10.1097/01.orn.0000470794.05868.ac

Nov 7, 2019Nov 7, 2019 at 3:34am

Hello Christian and class
The circumstances under which advanced practice registered nurses (APRN) work in Massachusetts is very similar to that of North Carolina. The two states have a considerable distance from each other. However, consistency in nursing practice is substantial. It goes to show that although nurses have the numbers in terms of people in the healthcare workforce, nurses have much work to do to establish the nursing practice as the significant power in healthcare. As it stands now, the nursing practice is straddled with the choices that are made for it. These choices are why nurses need to be adept in the political world as well as being expert healthcare providers. The effectiveness of the nurses’ abilities do not stop there; the nurses’ need to convey this wealth of information well, through speaking and writing. The next step consists of applying that which is learned as it is vital.

Nov 8, 2019Nov 8, 2019 at 7:47am

Christian, what are some of the pre-req’s for the different roles when applying for an MSN? For example, what experience is required to apply for a CRNA program vs a CNM program?

Nov 6, 2019Nov 6, 2019 at 11:03am

ADVANCED PRACTICE NURSE (APN)

WORK ENVIRONMENT	NURSE PRACTITIONER (CNP)	CERTIFIED NURSE-MIDWIFE (CNM)	CERTIFIED NURSE ANESTHETIST (CRNA)	CLINICAL NURSE SPECIALIST (CNS)
LEVEL OF ACCOUNTABILITY	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities, gynecologic care, postpartum and prenatal care, family planning **	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**	Highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**
PATIENT POPULATION	Everyone over their life span from birth to death, wide range of care settings including the home, clinics, and hospital **	Women over their life span from birth to death, their partners reproductive health, their partner’s sexually transmitted diseases, and newborns**	Everyone over their life span from birth to death**	Everyone over their life span from birth to death**
SALARY	Approximately $117,000**,******	Approximately $126,000******	Approximately $208,000*****	Approximately $119,000*******
SCOPE OF PRACTICE	Health promotion, counseling, disease prevention, referrals,** Restricted Practice,* Requires practice agreement with a currently licensed physician Can order treatments, medications and therapeutics**	Gynecologic care, newborn, Can order treatments, medications and therapeutics, health promotion, counseling, disease prevention, referrals,**	Persons in immediate to life-threatening circumstances, can order treatments, medications and therapeutics, health promotion, counseling, disease prevention, referrals,**	Health promotion, counseling, education, disease prevention, disease management, referrals, direct and indirect client care, No prescriptive authority**
POSITIVES	Expanded nursing role, able to work in a variety of settings	Independent service, does not need prescriptive authority requirements	Able to work with a wide range of clients	More similar than other APRN roles to the current register nurse role, therefore more familiar in that the CNS works according to the orders of another licensed professional
NEGATIVES	Need prescriptive authority requirement, must consult with a physician for certain prescriptions and/ or therapies	Narrow client base	Need prescriptive authority requirement, job consists of safely anesthetizing people and waking them up	Not authorized for prescriptive authority

The psychiatric clinical nurse specialist (PCNS) is an additional APRN role for a total of 5 APRN clinical categories in Massachusetts (Board of Registration in Nursing, 2019).

The reason for choosing the certified nurse practitioner practice role as opposed to any of the other advanced practice registered nurse (APRN) roles is because it allows for direct nursing care with an expanded role in that care. There is also the versatility of the CNP role. The CNP is able to work in any number of settings with a wide range of clientele. The CNP can also work as a primary care provider, which is very significant in nurse run establishments.

Plans for clinical practice after graduation is to work as a primary care provider in a local clinic, as well as continue with some bedside nursing in an inner-city hospital.

The perception of the CNP has changed since researching the topic. One perception regarding the idea of the CNP that has changed is the need for prescriptive authority. Another idea that has changed is the number of things that need to be done to acquire licensure to practice in Massachusetts.

References

*American Association of Nurse Practitioners. (2018). State practice Environment Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment

**Board of Registration in Nursing, Bureau of Health Professions Licensure, Department of Public Health. (2019). Learn about advanced practice registered nurses (APRN). Retrieved from https://www.mass.gov/service-details/learn-about-advanced-practice-registered-nurses-aprn

***Board of Registration in Nursing, Bureau of Health Professions Licensure, Department of Public Health. (2019). Learn more about prescriptive authority requirements and practice guidelines. Retrieved from https://www.mass.gov/service-details/learn-more-about-prescriptive-authority-requirements-and-practice-guidelines

****Glassdoor. (2019). Nurse practitioner salaries in Massachusetts. Retrieved from https://www.glassdoor.com/Salaries/massachusetts-nurse-practitioner-salary-SRCH_IL.0,13_IS3399_KO14,32.htm

*****Salary.com. (2019). Certified nurse anesthetist salary in Massachusetts. Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-anesthetist-crna-salary/boston-ma

******Salary.com. (2019). Certified nurse midwife salary Boston, Massachusetts Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-midwife-salary/boston-ma

*******Salary.com. (2019). Clinical nurse specialist salary in Boston, Massachusetts. Retrieved from https://www.salary.com/research/salary/benchmark/clinical-nurse-specialist-salary/boston-ma

********Salary.com. (2019). Nurse practitioner salary. Retrieved from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/ma

Nov 6, 2019Nov 6, 2019 at 2:03pm

post 1 NR510 Week 2

ADVANCED PRACTICE NURSE (APN)

ADVANCED PRACTICE NURSE (APN) MASSACHUSETTS

MASSACHUSETTS	NURSE PRACTITIONER (CNP)	CERTIFIED NURSE-MIDWIFE (CNM)	CERTIFIED NURSE ANESTHETIST (CRNA)	CLINICAL NURSE SPECIALIST (CNS)
WORK ENVIRONMENT	Private offices, home, nursing facilities, clinics, hospitals**	Private offices, home, birth centers, clinics, hospitals**	Private offices, home, nursing facilities, clinics, hospitals**	Private offices, home, nursing facilities, clinics, hospitals**
LEVEL OF ACCOUNTABILITY	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities, gynecologic care, postpartum and prenatal care, family planning **	Independent, highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**	Highest level accountability, accountable for advanced, assessment,referrals, diagnosis, treatment, and consultations for individuals to communities**
PATIENT POPULATION	Everyone over their life span from birth to death, wide range of care settings including the home, clinics, and hospital **	Women over their life span from birth to death, their partners reproductive health, their partner’s sexually transmitted diseases, and newborns**	Everyone over their life span from birth to death**	Everyone over their life span from birth to death**
SALARY	Approximately $117,000**,******	Approximately $126,000******	Approximately $208,000*****	Approximately $119,000*******
SCOPE OF PRACTICE	Health promotion, counseling, disease prevention, referrals,** Restricted Practice,* Requires practice agreement with a currently licensed physician Can order treatments, medications and therapeutics**	Gynecologic care, newborn, Can order treatments, medications and therapeutics, health promotion, counseling, disease prevention, referrals,**	Persons in immediate to life-threatening circumstances, can order treatments, medications and therapeutics, health promotion, counseling, disease prevention, referrals,**	Health promotion, counseling, education, disease prevention, disease management, referrals, direct and indirect client care, No prescriptive authority**
POSITIVES	Expanded nursing role, able to work in a variety of settings	Independent service, does not need prescriptive authority requirements	Able to work with a wide range of clients	More similar than other APRN roles to the current register nurse role, therefore more familiar in that the CNS works according to the orders of another licensed professional
NEGATIVES	Need prescriptive authority requirement, must consult with a physician for certain prescriptions and/ or therapies	Narrow client base	Need prescriptive authority requirement, job consists of safely anesthetizing people and waking them up	Not authorized for prescriptive authority

The psychiatric clinical nurse specialist (PCNS) is an additional APRN role for a total of 5 APRN clinical categories in Massachusetts (Board of Registration in Nursing, 2019).

Plans for clinical practice after graduation is to work as a primary care provider in a local clinic, as well as continue with some bedside nursing in an inner-city hospital.

References

*American Association of Nurse Practitioners. (2018). State practice Environment Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment

****Glassdoor. (2019). Nurse practitioner salaries in Massachusetts. Retrieved from https://www.glassdoor.com/Salaries/massachusetts-nurse-practitioner-salary-SRCH_IL.0,13_IS3399_KO14,32.htm

*****Salary.com. (2019). Certified nurse anesthetist salary in Massachusetts. Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-anesthetist-crna-salary/boston-ma

******Salary.com. (2019). Certified nurse midwife salary Boston, Massachusetts Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-midwife-salary/boston-ma

*******Salary.com. (2019). Clinical nurse specialist salary in Boston, Massachusetts. Retrieved from https://www.salary.com/research/salary/benchmark/clinical-nurse-specialist-salary/boston-ma

********Salary.com. (2019). Nurse practitioner salary. Retrieved from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/ma

Collapse Subdiscussion Navdeep Kaur

Navdeep Kaur

Nov 9, 2019Nov 9, 2019 at 5:46pm

Hello Arletha,

Thank you so much for your post. You did such a wonderful job putting everything into a chart. It makes it a lot easier to understand each different role of the advanced practice nurse in your home state. I am currently enrolled in the nurse practitioner program and unlike Massachusetts, Nurse Practitioners in California cannot practice independently. It’s nice to hear that all the advanced practitioners can practice independently in Massachusetts. That would be really nice if that was the case in California. But I see that someone needs to authorize the prescriptions that they prescribe. Does this mean that Nurse Practitioners must work close to an MD or DO? I know in certain states physicians need to a few miles near NP’s, is it the same in your state?

Dr. Storms,

I did not realize that a lot of primary care physicians were going into the administrator role. I should have because my own husband did primary care for a number of years and now does administration. This is great for us though this means our job will be in demand.

Nav Kaur

Nov 8, 2019Nov 8, 2019 at 7:49am

Arletha, it has been said that physicians are leaving patient care and moving towards consulting and administrative positions. The APRN is considered a highly educated registered nurse that has acquired educational status that may include a Masters degree or Doctorate degree. An APRN can diagnose, implement, evaluate, prescribe, and collaborate with other healthcare providers. With the use of evidence based practice, the APRN is able to provide the best care possible to her patients and also encourage/mentor fellow nurses. I believe that the addition of the APRN to the healthcare field helps alleviate the shortage of primary care providers. “Primary care physicians are increasingly frustrated and leaving the field or transitioning to nonclinical roles like consulting and administration” (Hariharn, 2015, p46).The prediction of 31% increase of APRN by 2026 is very promising for future advance nurse practitioners. Seeing numbers like that gives me encouragement that we will always have a place and position in the future of healthcare.

Nov 9, 2019Nov 9, 2019 at 6:04pm

Hello Dr. Storms
I agree that the information that physicians are leaving the bedside is promising for the advance practice nurse (APRN) in regards to the opportunity for job placement. However, there are lingering unanswered questions. The reasons why physicians are leaving the bedside have not been addressed, and the same problems will be inherited by the APRN’s that take their place at the bedside. This issue is compounded by the fact that although the nursing industry has made strides in regards to policies that affect the nursing practice, there is still a great way to go. Also, if the physicians were not able to overcome the obstacles that propelled them from the bedside, and they are the individuals who are well-positioned in terms of policies that affect the healthcare field, how will the APRN fare under these circumstances.

Nov 6, 2019Nov 6, 2019 at 3:02pm

There are different advance practice registered nurse roles (APRN’s) here in New Jersey such as Certified Nurse Practitioner (CNP), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), and Certified Nurse Anesthetist (CRNA). Each ARPN roles has its own scope of practice, level of accountability, working environment, patient population and different salary for each APRN role. Below are the identified different APRN’s in the state of New Jersey.

Certified Nurse Practitioner’s (CNP’s) in New Jersey are licensed as APRN’s by New Jersey board of nursing. CNP’s scope of practice includes collaboration (using standard care arrangement) with a physician when providing patient care. In addition, CNP’s scope of practice includes providing primary care and preventative care services, manages chronic or acute disease in different settings, promotes wellness and evaluates patient health, orders diagnostics test and laboratory test and interprets them, prescribes medication and other therapeutic devices, and CNP’s performs procedures. The CNP’s work environment differs on subspecialty such as Family Nurse Practitioner (FNP), Adult/Gerontology Primary Care (AGPCNP) and/or Pediatric Primary Care (PPCNP) mostly seen in a family practice setting such as Doctors office, clinics and other primary care setting facility. While, Adult/Gerontology Acute Care (AGACNP) and/or Pediatric Acute Care (PACNP) can be seen in acute care setting such as emergency department, hospital, and other acute care setting. Moreover, Neonatal Nurse Practitioner (NNP), Women’s Health Nurse Practitioner (WHNP), and Psychiatric/Mental health (PSMHNP) can also be seen in hospital or primary care settings (Ellenbecker & Edward, 2016). The CNP’s accountability or responsibility is to provide health promotion and disease prevention, health education, diagnosis and treatment of chronic or acute illnesses. CNP is also accountable in providing the highest level of patient care and promote safety to the public. In addition, CNP is responsible to follow the New Jersey’s APRN Standard of practice law, failure to follow can compromise the holders license to practice (NCSBN, 2019). Furthermore, the patient population is based on the CNP’s sub specialty for example, FNP sees patient from new born to older adults in a primary care setting while pediatrics nurse practitioner can only see pediatrics populations. The salary of CNP is affected by the sub specially and the demand, for example PSMHNP is in demand but there are a smaller number of certified PSMHNP here in New Jersey therefore they are salary are higher than the subspecialty of CNP (Ellenbecker & Edward, 2016). The average salary of CNP here in New Jersey ranges from $96,855 to $114,101. These salary range here in New Jersey is affected by the CNP’s number of related work experience, education, certifications and the city where the practitioner currently lives and practicing (“Nurse Practitioner Salary by State”, 2019).

The Certified Nurse Midwife (CNM) is one of APRN important role in New Jersey. The CNM scope of practice here in New Jersey includes providing primary health services to all adolescent women and beyond menopause, provides primary care services that will help women at the time of pregnancy, labor and at birth. CNM’s also work hand in hand with OBGYN doctors. CNM’s performs reproductive and gynecologic annual exams, provide services to all menopause women, promotes and provides sexually transmitted disease treatments, provides education and counseling such as parenting education, and or basic nutrition education, they also prescribe medications, performs vaginal tears repair and episiotomies, and assist with or perform normal vaginal birth. However, according to Marzalik, Feltham, Jefferson & Pekin (2018), CNM’s are encouraged not to perform or deliver a breech or face presentation, perform version, the use of forceps, performs obstetric operations, or treat other pregnancy or delivery abnormal condition unless in an emergency situation. CNM’s must also have standard care arrangement with the collaborating OBGYN doctor. The work environment of CNM’s is mostly seen in women’s health clinic, healthcare center, OBGYN offices and other primary care setting that provides care primarily to women’s health. The accountability or responsibility of CNM’s is to follows the New Jersey CNM standard of practice defined by the American College of Nurse Midwife. CNM is responsible to the patient population such as new born, women’s health and pregnancy (Marzalik et al., 2018).

Clinical Nurse Specialist (CNS) scope of practice provides direct healthcare services to families, groups or individuals in accordance to the New Jersey board of nursing APRN practice act. The CNS is skilled and highly competent in their respective specialized area of interest such as consulting, education or research. CNS can also obtain their prescribing medication authority if they want to. Currently, here in New Jersey it is not required for CNS to have authority to prescribe medication and of course CNS who do not have prescribing authority are not allowed to prescribe medication to their patients (Mayo, Harris & Buron, 2018). The work environment of CNS is usually in an acute care setting but due to their broad knowledge and skills it helps them to work in universities, private offices or businesses, clinics, hospitals, and other non-acute home care services. The CNS is accountable and responsible for health promotion and disease or illness prevention, diagnosis, provides treatment of certain diseases, disease and risk behavior management within the community, family, groups or individuals (NCSBN, 2019). The CNS practices in a variety patient population such as pediatrics, adult/gerontology, Family or individual across life span, neonatal or Women’s Health (Mayo, Harris & Buron, 2018). The average salary of CNS is the state of New Jersey ranges from $92, 223 to $112,643 annually which is affected by the years of work-related experience, city of residence, level of education and certifications (“Nurse Practitioner Salary by State”, 2019).

The scope of practice of Certified Nurse Anesthetist (CRNA) is to provide professional functions and privileges in accordance to the nurse anesthesia practice as well as anesthesia care related across the lifespan. CRNA are required to practice with supervising physician, dentist, or podiatrist. According to Robins & Rosenbaum (2015), the work environment of CRNA includes, dentist office and hospital surgical suites. The accountability or responsibility is to provide primarily anesthesia care to their patient. Also, they are accountable for keeping and maintaining clinical and skills competency. CRNA is accountable for providing safe patient care and the use of critical thinking. CRNA’s provides care for the patient population who are undergoing surgery that requires anesthesia and post anesthesia care (men or women, pediatrics, adults, and or neonates) (Robins & Rosenbaum, 2015). The salary of CRNA in New Jersey ranges from $164,104 to $194, 602 annually and of course it varies based on the individual’s years of experience, education, certification and the city in which the individual currently residing (“Nurse Practitioner Salary by Sate”, 2019).

APRN roles

Pros

Cons

CNP

1. Making a difference

2. Interesting and diverse job

3. Camaraderie with co-workers

4. More opportunities

5. Mentor opportunities

6. Income

(Brassard, 2014)

1. Exposed to virus and germs

2. High responsibility- means increase stress

3. Deals with traumatic patient situation

4. Competition

5. Bias against Nurse practitioner

6. Lack of formal residency program

7. Different state and different variations with NP practice.

(Brassard, 2014).

CRNA

1. Pay

2. Autonomy

3. Professional respect

4. Ability to help others

(Brassard, 2014)

1. Responsibility

2. Long work hours

3. Competition

(Brassard, 2014).

CNM

1. Develops good patient relationship

2. Trained in specialized care

3. Provides holistic approach

4. Provides gynecologic care

5. Midwife’s care is as safe as care from a doctor.

(Brassard, 2014).

1. Bias against male midwife

2. Sex related job

3. Unqualified to manage high risk pregnancy

4. Limited procedures such as CNM are not qualified to perform c-section.

(Brassard, 2014).

CNS

1. Online study

2. Greater autonomy

3. Career options

(Brassard, 2014)

1. Time and money spent

2. Lower pay than other APRN roles

(Brassard, 2014)

Nursing is a rewarding profession, as a current working Registered Nurse within the population of acutely ill adults, it is my pleasure to care for them. But I feel like what I do for them is not enough. I wanted to widen my scope of practice to advance my nursing degree into a more complex and high demand responsibility such as Nurse Practitioner. Reasons that made me wanted to pursue my (MSN) Master of Science in Nursing with a concentration in Family Nurse Practitioner (FNP) is being able to make a change or positively impact to people’s lives. The concept of having a higher level of responsibility as a nurse practitioner excites me knowing that I can be able to make a difference to all my patients lives. I want to be part of a positive change on my patient well-being as well as in the community of complex acute or chronically ill patient. I think that becoming a Family Nurse Practitioner (FNP) versus CRNA, CNS or CNM will allow me to provide advance care across the lifespan. Also becoming an FNP will help me focus my attention and problem solve base on the specific needs of my patients. I enjoy the idea of being responsible in studying or investigating the pathophysiology of the disease and formulating an effective intervention or treatment that will aid in the healing process of my patient. Also, the idea of having an advanced critical thinking will help me provide an evidence-based intervention or treatment that my patient well-being will benefit from.

My plan after graduation is to make sure that I pass the board exam so that I can start practicing as APRN. I also wanted to pursue my career in a family practice setting like a mobile clinic setting that manages chronic or acute illness. But I am the kind of person that will take whatever opportunity comes my way. Because I believe that the more experience, I gain will ultimately help me get to where I want to be. After researching the different APRN roles in my states it gave me more knowledge in regards to their respective scope of practices, however my idea of FNP Practice here in New Jersey did not change because currently, I work side by side with different FNP’s and constantly interact with them which gave me an idea to what their role entails.

References

Brassard, A., (2014). Overview and summary: APRN roles: Opportunities and challenges for practice and education. OJIN: The Online Journal of Issues in Nursing, 19(2), 10-13. DOI: 10.3912/OJIN.Vol19No02ManOS

Ellenbecker, C. H., & Edward, J. (2016). Conducting nursing research to advance and inform health policy. Policy, Politics, & Nursing Practice, 17(4), 208-217. doi:10.1177/1527154417700634

National Council of State Boards of Nursing (2019). APRNS in the U.S. Retrieved from https://ncsbn.org/aprn.htm

Nurse Practitioner Salary by State. (2019). Nurse Journal. Retrieved from https://nursejournal.org/nurse-practitioner/nurse-practitioner-salary-statistics/ (Links to an external site.)

Marzalik, P. R., Feltham, K. J., Jefferson, K., & Pekin, K. (2018). Midwifery education in the u.s. – certified nurse-midwife, certified midwife and certified professional midwife. Midwifery, 60, 9-12. doi:10.1016/j.midw.2018.01.020

Mayo, A. M., Harris, M., & Buron, B. (2018). Integrating geropsychiatric nursing and interprofessional collaborative practice competencies into adult-gerontology clinical nurse specialist education. Clinical Nurse Specialist, 30(6), 324-331. doi:10.1097/nur.0000000000000248

Robins, H., & Rosenbaum, S. H. (2015). Certified registered nurse anesthesia: Critical care nursing in the operating room. Critical Care Nursing Clinics of North America, 27(1), I. doi:10.1016/s0899-5885(14)00095-1

Nov 8, 2019Nov 8, 2019 at 7:51am

Youseline, all of the different roles have an immense amount of responsibility, just in different ways. As nurses, I feel that we are held to a high standard of responsibility no matter what role we are in. We often times hold another person’s life in our hands and that holds a great deal of responsibility. The role we choose should involve our interests and a lot of thought about where we want to place our responsibility. For example, as a CNM, one will have a lot of responsibility when it comes to helping bring a new life into this world. Another path one could take is working in the operating room and being responsible for providing appropriate anesthesia to a surgical patient. Ultimately, all of nursing holds a great deal of responsibility and our decision needs to come from our individual perspective, with a lot of thought about all the different roles we can work in. It sounds like your heart lies in the FNP role and that is a great role to be in! I hope you love it as much as I do!

Nov 6, 2019Nov 6, 2019 at 3:06pm

Week 2: Advanced Practice Nursing (Orig Post due Wednesday, Responses due Sunday)

Dr Storms and class,

APRN roles

Pros

Cons

CNP

1. Making a difference

2. Interesting and diverse job

3. Camaraderie with co-workers

4. More opportunities

5. Mentor opportunities

6. Income

(Brassard, 2014)

1. Exposed to virus and germs

2. High responsibility- means increase stress

3. Deals with traumatic patient situation

4. Competition

5. Bias against Nurse practitioner

6. Lack of formal residency program

7. Different state and different variations with NP practice.

(Brassard, 2014).

CRNA

1. Pay

2. Autonomy

3. Professional respect

4. Ability to help others

(Brassard, 2014)

1. Responsibility

2. Long work hours

3. Competition

(Brassard, 2014).

CNM

1. Develops good patient relationship

2. Trained in specialized care

3. Provides holistic approach

4. Provides gynecologic care

5. Midwife’s care is as safe as care from a doctor.

(Brassard, 2014).

1. Bias against male midwife

2. Sex related job

3. Unqualified to manage high risk pregnancy

4. Limited procedures such as CNM are not qualified to perform c-section.

(Brassard, 2014).

CNS

1. Online study

2. Greater autonomy

3. Career options

(Brassard, 2014)

1. Time and money spent

2. Lower pay than other APRN roles

(Brassard, 2014)

References

Ellenbecker, C. H., & Edward, J. (2016). Conducting nursing research to advance and inform health policy. Policy, Politics, & Nursing Practice, 17(4), 208-217. doi:10.1177/1527154417700634

National Council of State Boards of Nursing (2019). APRNS in the U.S. Retrieved from https://ncsbn.org/aprn.htm

Nurse Practitioner Salary by State. (2019). Nurse Journal. Retrieved from https://nursejournal.org/nurse-practitioner/nurse-practitioner-salary-statistics/ (Links to an external site.)

Reply Reply to Comment(1 like)

Collapse Subdiscussion Carrie Wolhart

Carrie Wolhart

Nov 6, 2019Nov 6, 2019 at 3:21pm

Professor and class,

I have learned a magnitude of things related to each of the advanced practice roles for nursing. As nurses we truly have so many options! I first looked at the salary ranges for each of the practices and was surprised to find how they varied from state to state. The salaries I focused on were those in Oklahoma. Salary ranges for the CNP in Oklahoma are between 85,880 to 143,480 and ranges for the CNS are between 94,720 and 114,754 (nurse.org). There are many similarities in the CNS and the CNP. Both programs take around the same time to complete, and both must have a BSN prior to obtaining their masters degree (nurse.org). Both the CNP and the CNS are expected to have a rapid growth rate and remain in demand (nurse.org). The CNS may work in physician’s offices, hospitals, outpatient care centers, colleges and universities, community centers, and laboratories (nurse.org). Their scope of practice varies state to state, but in Oklahoma, they must have a supervising physician as does the CNP including a collaborative agreement (nurse.org) Both the CNP and the CNS have to pass a antional certification exam. CNPs may work in hospitals, outpatient settings, long-term care facilities, private duty, hospice and palliative care, government and community agencies, universities and research agencies, and private practice (nurse.org). The CNS may specialize in adult healt, adult psych, child/adolescent psych, gerontology, home health, diabetes management, pediatrics, and public/community health (nurse.org) The CNP may specialize in family (primary or acute), pediatric (primary or acute), neonatal, adult gerontology (primary or acute), trauma, emergency care, women’s health, psychiatric or mental health (nurse.org). The main role of the CNS is expert consultation, applying evidence – based research, patient outcomes, system outcomes improvement, educate and train staff, andhealth care administration (nurse.org). The main roles of the CNP are health assessment and diagnostic testing, promotion of disease prevention, patient/family education, diagnosing and treating, provide specialty referrals, prescriptive authority, and direct patient care (nurse.org). The CNM treats the pregnant population and may follow them after birth for a period of time (Writers, 2019). They are able to work in private clinics or in the hospital setting (Writers, 2019). Once obtaining a BSN, one must work for two years in a related field then enter an accredited midwife program (Writers, 20149). CMNs also show a failry rapid growth rate in the market (Writers, 2019). The salary range for a CNM in oklahoma is around 70,000 and is about 8% lower than the national average (Writers, 2019). The CRNA treat patients of all ages through the use of anesthesia before and after surgery (Writers, 2019). CRNAs may practice in hospitals or outpatient surgery centers. Once a BSN is obtained a degree in master of science in nursing must be obtained. A doctoral certificate is required in the state of Oklahoma (Writers, 2019). The CRNA role also shows a rapid growth in the market for the future (Writers, 2019). The average salary for a CRNA is 127,00 in Oklahoma (Writers, 2019). This role also falls below the national average. I do not feel that I would excel in anything but CNP. I need direct patient care, and after seeing poor treatment given by some providers, I aim to give the best care possible to my patients. I did think briefly of going into anesthesia as that is what my father does, but after contemplating for a while, I decided that I would ultimately like to work in my own practice. Being a CNM has never crossed my mind as obstetrics is just not for me. Many of the hospitals in Oklahoma are phasing out the FNPs within the hospital setting. I feel that if I would like to get back in the acute setting, I will obtain my certification later in my career. I truly feel that I can make a difference in a rural clinic and that is where I feel I will land after I obtain my certification. I do like all ages and feel that FNP is the best for me especially in a rural setting. Patients have such a hard time getting to and from appointments when they have to travel an hour each way. Although I have learned quite a bit related to the other APN roles, I do not feel that any of it has changed my thoughts on my career path.

Clinical Nurse Specialist (CNS) or Certified Registered Nurse Practitioner (CRNP)? (n.d.). Retrieved November 5, 2019, from https://nurse.org/articles/cns-vs-cnp-which-career-path-is-right-for-you/ (Links to an external site.).

Writers, S. (2019, November 6). Nursing Anesthetist Careers & Salary Outlook – 2019 NurseJournal.org. Retrieved from https://nursejournal.org/nurse-anesthetist/nursing-anesthetist-careers-salary-outlook/ (Links to an external site.).

Writers, S. (2019, November 5). Nursing Midwife Careers & Salary Outlook – 2019 NurseJournal.org. Retrieved from https://nursejournal.org/nursing-midwife/nursing-midwife-careers-salary-outlook/ (Links to an external site.).

Nov 8, 2019Nov 8, 2019 at 7:52am

Carrie, I am going to turn the conversation here a little bit. With the NP role, there are barriers (state, payer policies, MDs, etc). Some MDs view PAs as a greater asset to practice than NPs. Many MDs, especially the older ones, prefer PAs over NPs and often ask NP students why they didn’t go to school to be a PA instead. This creates a barrier for us. What could you say to an MD who poses this question?

Collapse Subdiscussion Carrie Wolhart

Carrie Wolhart

Nov 10, 2019Nov 10, 2019 at 5:44pm

Professor Storms,

That’s a tough question that I have actually heard several times since deciding on FNP. I have decided that NP better fits with my nursing philosophy that the PA. As a nurse, we treat patient’s holistically and I aim to continue that in my NP career. I would inform the MD that I prefer a holistic and preventative approach for patient care. Also, the majority of PAs hold a surgical specialty which is something I am not interested in. I prefer to help rural Oklahomans obtain proper healthcare without having to drive an hour to a larger city. I have actually had this discussion with a few MDs that I work closely with and they seem to understand that it boils down to a philosophical difference. Some have even agreed that NP may be a better route since insurance is gearing more towards preventative medicine. I was told by an orthopedic surgeon that pairing with an NP may be a better asset and would bring a different view to his practice. In Oklahoma, it seems that the NP has to obtain collaboration where the PA must have direct oversight in practice. In the conversations I have had with providers, most understand my decision.

Collapse Subdiscussion Katy Claus

Katy Claus

Nov 6, 2019Nov 6, 2019 at 4:03pm

There are four advanced nursing practice (APN) roles, all of which including different roles and responsibilities. These APN roles include Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), and Certified Nurse Practitioner (CNP). This discussion will outline the responsibilities and abilities of each of these roles, as well as personal pros and cons for each.

Certified Nurse Midwife (CNM)

A CNM works in collaboration with a physician or a private midwife facility to help mothers and infants prepartum, intrapartum, and postpartum. CNMs can work within hospitals or wherever their collaborator approves, which may include someone’s home. In the state of Nebraska CNMs must work with a collaborator, which assumes responsibility for direction of medical actions a CNM must take. They work with expecting mothers, while forming a relationship with them, making the process more comfortable and soothing for expectant families. However, CNMs can also provide gynecologic and obstetric care, rather than just being with the mother throughout the course of her pregnancy. Some CNMs are chosen to be a woman’s primary care provider after forming their relationship (“Online Midwifery Schools,” 2019). The average salary of a CNM in Omaha, NE is about $102,900 (“Certified Nurse Midwife Salary in Nebraska,” 2019).

Pros: Cons:

Help women create and care for their families – Unpredictable work hours
Provide care for mother and child – High stress situations
Average salary is adequate – May not be in hospital setting

(“Online Midwifery Schools,” 2019)

Clinical Nurse Specialist (CNS)

A CNS is an APRN that has the ability to assess, diagnose, and treat patients with ongoing illness. They are able to be specialized in many areas. They are able to see patient populations anywhere from children to geriatrics, depending on their specialty. A CNS often focuses on research and development of healthcare, working with a lot of evidence-based practice information. Typically, a CNS works with education and promoting health through education. Although in many states they are required to work with a collaborator, in the state of Nebraska, a CNS has full scope of practice, meaning they are not required to have a collaborator (“What is a CNS,” 2019). The average salary of a CNS in Omaha, NE is $99,694 (“Clinical Nurse Specialist Salary in Nebraska,” 2019).

Pros: Cons:

Full scope of practice – typically focus on research
Can specialize in any desired area – focus on educating RNs often
Assess, diagnose, and treat – less utilized than NPs

– lower salary

(“What is a CNS,” 2019)

Certified Registered Nurse Anesthetist (CRNA)

A CRNA is responsible for working alongside physicians, surgeons, anesthesiologists, etc. in order to safely administer anesthesia to patients for surgeries and procedures. They are also specialized in pain management, epidurals, nerve blocks, etc. The work environment for a CRNA may be a hospital, outpatient clinic, military bases, and offices. In addition to providing anesthesia for expectant mothers, patients undergoing surgery, etc., a CRNA also provides education and follow-up regarding anesthesia and medications given. Depending on the setting, patient population can be children to geriatrics for CRNAs. They are accountable for their actions and the competence there of (“What is a Nurse Anesthetist,” 2019). The average salary of a CRNA in Omaha, NE is $173,443 (“Certified Nurse Anesthetist Salary in Nebraska,” 2019). NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

Pros: Cons:

Excellent pay – grueling schooling
Autonomy – high risk/stressful
Work alongside surgeons – chemistry knowledge
Pain management

(“What is a Nurse Anesthetist,” 2019)

Certified Nurse Practitioner (CNP)

A CNP works to assess, diagnose, and treat both chronic and acute illness in the healthcare field. They have the ability to order and read test results. CNPs have can work in many different environments, typically in an office environment. They have the ability to see patients of all ages and specialties. Although many are primary care providers, they can also specialize in specific areas. In Nebraska, CNPs have full scope of practice, meaning they do not have to work under a physician. There is no collaboration necessary. However, this does mean that a CNP carries all of the accountability for their actions and treatments (“State Practice Environment,” 2018). The average salary of a CNP in Omaha, NE is $101,966 (“Nurse Practitioner Salary in Nebraska,” 2019).

Pros: Cons:

Able to specialize – pay is less than CRNA
Assess, diagnose, and treat – full accountability
Full scope of practice in Nebraska
Normal hours

(“State Practice Environment,” 2018)

I chose the CNP role over the other three for many reasons. First of all, I would not want to be a midwife because I am not a big fan of obstetrics. This has never been an interest of mine, and I have no experience in that area. Also, I would not want to work all hours of the day. I never thought of going the CNS route. I have heard that they are being utilized less and less. Although I appreciate research and EBP, I do not want to dedicate majority of my career to it, nor would I want to be an educator. Although these are portions of the CNP role, they are not the primary role. I thought about becoming a CRNA. This was my original plan. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse However, CRNA schooling is very aggressive, as it should be, and does not typically allow students to work during. Also, I like to interact with my patients, and a CRNA would have much less of this. Overall, I chose the CNP role because there are endless options. After graduation I intend to work as a nurse practitioner specializing in cardiology. I would like to work in a heart failure clinic or something of that nature. Cardiology is my passion, and I am hopeful that I will be able to stay in that lane. My idea of the NP role has changed a little since researching it in my current state. Since I just recently moved, I was not aware that NPs have full scope of practice in Nebraska. Therefore, I was delighted to find out that they are not required to have a collaborator as they were in my previous state. Other than that, I do not think my idea of the NP role has really changed. I worked alongside a lot of NPs in my old position, so I was able to research and ask them questions about what to expect! NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

References

Certified Nurse Anesthetist Salary in Nebraska. (2019). Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-anesthetist-crna-salary/ne?citykeyword=omaha

Certified Nurse Midwife Salary in Nebraska. (2019). Retrieved from https://www.salary.com/research/salary/benchmark/certified-nurse-midwife-salary/ne?citykeyword=omaha (Links to an external site.)

Clinical Nurse Specialist Salary in Nebraska. (2019). Retrieved from https://www.salary.com/research/salary/benchmark/clinical-nurse-specialist-salary/ne?citykeyword=omaha

Nurse Practitioner Salary in Nebraska. (2019). Retrieved from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/ne?citykeyword=omaha

Online Midwifery Schools Offering CNM Master’s Degrees in Nebraska. (2019). Retrieved from https://www.midwifeschooling.com/nebraska/ (Links to an external site.)

State Practice Environment. (2018). Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment

What is a CNS? (2019). Retrieved from https://nacns.org/about-us/what-is-a-cns/ (Links to an external site.)

What is a Nurse Anesthetist1? (2019). Retrieved from https://www.nursepractitionerschools.com/faq/what-is-a-nurse-anesthetist/ (Links to an external site.)

Hi,

I couldn’t agree more with you on your decision in choosing CNP. I originally wanted to go to anesthesia school. My father has been a CRNA for many years and owns his own company that allows him to work contracts with facilities. He has the best job in that he can work 3 days a week and make the same that other CRNAs make employed by facilities. I wanted a job like that! When I moved to the ICU for my critical experience for school, I saw how hard the CRNAs worked and how little the MDAs did NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse. I became very skeptical and decided I wanted my own practice. I did not like obstetrics at all so I knew that CNP was for me as I wanted to remain in direct patient care. In Oklahoma, CNPs must have a collaborator, but the association of nurse practitioners for my state is vigilantly lobbying for less oversight. I have physicians that I have worked well with in the past that are willing to provide me oversight, but it would be nice to not have documented collaboration with them. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

Great, . How do you feel about the salary differences across the different roles?

Professor,

I feel that the average salary seems fair across the board. Salaries are very similar for a CNP, CNS, or a CNM. Although it would be great to make a CRNA salary as a CNP, I do understand why they are paid more than the other three APRN roles. I think that the responsibility and accountability among a CNP, CNS, and a CNM are quite similar. Therefore, it makes perfect sense why they would each make around $100,000 annually. On the other hand, I believe that a CRNA takes on somewhat of a more risk-filled role. A CRNA is specialized in anesthesia and the way these medications affect each individual chemically. Their knowledge is more specified, but can also be extremely detrimental to their patients. Like nurse practitioners, they are held accountable for their actions and decisions in the state of Nebraska. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse. I do not intend to imply that a CNP, CNS, or a CNM do not hold patient’s lives in their hands or that their work is not incredibly difficult or risky. However, I believe that they carry less risk than that of a CRNA. In order to become a CNP, CNS, or CNM schooling generally requires about five-hundred clinical hours. However, CRNAs have a much heavier master’s program, typically requiring over eight thousand clinical hours (“NP vs CRNA,” 2019). As I mentioned before, nurses working toward their CRNA are not typically allowed to work during. The schooling is gruesome and incredibly demanding. Although I do not feel that schooling alone should be the reason someone makes more money, it is a factor. Overall, I do feel that the salary among APRN roles is adequate and fair. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

References

NP vs CRNA. (2019). Retrieved from https://www.nursepractitionerschools.com/faq/np-vs-nurse-anesthetist/

CNM- Work in a clinic or in a hospital to work with labor/expecting mothers. Can work with a physician or independently. Salary is said to be 100,320 by RNtoMSNedu.com. Can work independent or with an obstetrician.

CRNA- Can work inpatient or outpatient, more jobs are inpatient. Will work autonomously in an operating room. Will see patients of any age or gender, Salary is said to be $239,140 by RNtoMSNedu.com.

CNP- Work in inpatient or outpatient, more jobs are outpatient. May act as a primary care provider, however as a nurse practitioner there must be a physician agreement to be available should an emergency arise. Will see patients of any age or gender, Nurse practitioners can prescribe medications up to a schedule II drug. Salary is said to be 96,980 by RNtoMSNedu.com. (Barton associates: Nurse practitioner scope of practice laws, 2019)

CNS- Work more on the peripheral than other APRNs. Works to increase education and improve current practice. Can work with any population. Salary is average around $104,361 according to Salary.com.

Personally the pros are the flexibility of the job. There are so many different environments for a CNP to practice, whether inpatient or outpatient is a huge advantage. In addition there is other directions the degree can be used for, such as teaching others in the subject that the person is passionate about. Another pro knows that you as the care provider are the front-line for prevention. “NPs have historically been champions of preventive healthcare and primary care” (Davis, Guo, Titler, & Firese, 2016). NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

As for cons there is a primary care shortage on the rise in the United States. (Ramira, 2019, pg 20). This shortage has the risk of leaving little opportunity in specialties and forcing nurse practitioners to treat patients in a primary care environment.

The rationale behind pursuing the CNP track over other tracks was the versatility. Even though I am incredibly passionate about palliative medicine and would like to secure a job and work with palliative, I did not want to limit my opportunities. With CNP there is an ability to teach like a CNS, and to work in the same specialties as a CRNA and CNM, although it would not be to the same degree. It is the versatility that made this path so compelling.

Upon graduation my intent is to try and secure a job within palliative medicine. It has always been a passion to care for those when their time is limited. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse. Making the most of the quality of life when the quantity may be limited is something that is near and dear to my heart, not only professionally, but also personally I find it incredibly important.

After researching nurse practitioner guidelines for practice my idea has not changed. The idea of going back to school and choosing this route was a calculated choice that had research in my state before pursuing this path. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

Best regards

References

Barton associates: Nurse practitioner scope of practice laws. (2019). Retrieved from https://www.bartonassociates.com/locum-tenens-resources/nurse-practitioner-scope-of-practice-laws.

Davis, M. A., Guo, C., Titler, M., & Firese, C. R. (2016). Advanced practice clinicians as a usual source of care for adults in the United States. Nursing Outlook, 65 1-9. doi: 10.1016/j. outlook.2016.07.006

Ramira, M. L., Peraza-Smith, G. B., McLeod, R., & Clark, M. J. (2018). Challenges, barriers, and satisfiers of foreign educated physicians with the family nurse practitioner role in the United States. Journal of Cultural Diversity, 25(1), 12–22. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

https://www.rntomsnedu.org/wisconsin/wisconsin-salary/

Haley, so often patients talk about how hard it is to get in to see a PCP. Let’s consider the gap and how we can help close this gap. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse That is one of the reasons I entered this field. The gap is HUGE and the MDs cannot fill it alone. Many MDs don’t care for NPs; they see us as a threat rather than a help. It is important to work for an MD that appreciates NPs and sees how helpful we are to healthcare and closing the gap. This is something to consider when you start looking for jobs. Make sure the supervising MD sees you as a help and not a hinderance. The MD who hires NPs but sees them as a hinderance is one to stay away from. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse.

Dr ,

It is so difficult to get in to see a primary care doctor. Family nurse practitioners will be so helpful in closing this gap if they are allowed to partake in care. However I have seen this resistance to having an advance practice nurse filling a role that could be filled by a physician. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice NurseSometimes it is viewed as competition when the role is intended to be a partnership. Both parties have the ultimate goal of what is best for the patient, and ego of one should not hinder this goal of success. However, I have also seen the opposite side of this spectrum. A physician that has a beautiful partnership and work together to promote patient health are able to benefit many more patients than one party alone would be able to benefit. This partnership is a beautiful thing that will end up being able to help many patients reach their best self with their health goals powering their care. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse.

Best regards,

Haley

The Affordable Care Act created increased access to primary care providers in the U.S. Increased access to primary care is associated with lower mortality rates and lower costs due to better preventive care, lower hospitalization rates, and the reduction of unnecessary specialty care. Nurse practitioners can provide most of the primary care services commonly provided by physicians, with at least comparable outcomes and at lower cost. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse. NPs have similar types of malpractice claims to those of physicians, but lower malpractice rates. Nurse practitioners score consistently higher in patient satisfaction, patient compliance, health promotion, and disease prevention. I chose the family nurse practitioner route due to the versatility of practicing in a wide variety of settings. Other reasons were that the length of education is shorter and the cost of tuition is less expensive than that of medical school. Due to having a nursing background, nurse practitioners have a patient-centered care approach, which corelates with higher patient satisfaction. Ironically, these same reasons are why some physicians disapprove of or feel threatened by nurse practitioners. The reality is that nurse practitioners are able to fill the growing primary care shortage quicker than physicians, since it takes NPs, on average, six years to complete their education and training, including undergraduate and graduate degrees, compared to an average of 11 to 12 years for physicians, including schooling and residency training (Cabbabe, 2016). Some physicians believe nurse practitioners provide a lower quality of care because of the shorter length of schooling, but I disagree. Nurse practitioners may not be appropriate for every patient situation. However, just as all primary care physicians are trusted to know when to refer to a specialist, nurse practitioners should be trusted to know when to seek consultation from, or refer to, a physician colleague. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse.

Kim Logsdon

References

Cabbabe, S. (2016). Should Nurse Practitioners Be Allowed to Practice Independently? Missouri Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139780/

Hello H,

I agree with your ideas about the versatility and many options that are out there for a Certified Nurse Practitioner to follow. CNP’s can teach, do research, take account of evidence-based research and work it into their practice, prescribe, do preventative care/teaching and chronic as well as acute treatment of patient concerns. CNP’s can work in Family practice, Adult care, Women’s Health, Pediatrics, Cardiology, Oncology, Gerontology as well as some offshoot specialties of care. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse.

Palliative Care Medicine is a field that I have worked in as an aid before I decided to go back to school and get my RN-BSN degree. Palliative care is a field that is seldom thought of in the field of nursing but is a necessary one for those that have gotten tired of getting treatments or are not wanting to hurt anymore. Palliative/hospice Care CNP’s/Physicians, nurses and aids can make the person who is not actively being treated to be healed anymore, as well as those that are aggressively being treated, as comfortable as possible. Palliative care is a totally different thought process in terms of medicine but can allow the patient to be as comfortable as possible until the final days of their lives, or until the treatments have come to an end. Palliative care can be very helpful in the last days of a person’s life, as well as integrating palliative care into active and aggressive treatments, so that the patient can have the best possible life in both circumstances. “By integrating palliative care into primary care or “primary palliative care,” primary care providers can assess and address basic symptom management, assist with advance care planning (Links to an external site.), and conduct ongoing goals of care discussions to align care with patient priorities” (Dudley et al, 2018).

References

Dudley, N., Ritchie, C. S., Wallhagen, M. I., Covinsky, K. E., Cooper, B. A., Patel, K., … Chapman, S. A. (2018). Characteristics of Older Adults in Primary Care Who May Benefit from Primary Palliative Care in the U.S. Journal of Pain and Symptom Management, 55(2), 217-225. doi:10.1016/j.jpainsymman.2017.09.002. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse.

Hi H,

I completely agree with you about the versatility and options available for CNPs. It provides us with the opportunity to work in many different patient care settings. I also find your passion for palliative care special. I personally have a special place in my heart for palliative and hospice care. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse. I did some time In home hospice as well as a year on an oncology/palliative unit in the hospital. Much of the inspiration for me to go back to school to become an NP was due to working next to and collaborating with some amazing palliative NPs. One reason that I left that unit however, was the emotional toll that it took on me to see hurting families and dying patients almost every single day. It has been determined that those who work in this setting have higher rates of “burnout”. (Kamal et al., 2016) Do you find this to be true in your case? Do you have any special tips to combat it? NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

References

Kamal, A. H., Bull, J. H., Wolf, S. P., Swetz, K. M., Shanafelt, T. D., Ast, K., … Abernethy, A. P. (2016). Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. Journal of pain and symptom management, 51(4), 690–696. doi:10.1016/j.jpainsymman.2015.10.020

According to NCSBN.org all advanced practice registered nurses are educated at least to a master’s level and may assess, diagnose, order tests and prescribe medications. (APRNS in the U.S.,2019)

Clinical Nurse Specialist
This type of advance practice nurse is focused not only on the diagnosis, prevention and treatment of disease, but they are also focused on populations and systems of care. They can be seen doing quality control research, education, as well as contributing to patient care. (APRNS in the U.S.,2019) They may care for a wide patient population and can be seen working in hospitals, with home health organizations and government entities such as health departments. According to Payscale.com the average clinical nurse specialist salary is $88,715 yearly.(payscale.com, 2019) NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse
Personal pros: Ability to effect change and educate for better patient care.
Personal Cons: More likely to deal with large populations and fewer individual patients

Certified Registered Nurse Anesthetist
These advance practice nurses are trained to provide anesthesia care to patients across the lifespan and whether sick or healthy. They are typically seen working in operating rooms and managing patient’s pain relief both during and after procedures. (APRNS in the U.S.,2019) They are also instrumental in managing the patient’s response to analgesic medications and assisting to maintain the stability of the patient while under anesthesia. According to payscale.com the average yearly salary for a certified nurse anesthetist is $147,603.(payscale.com, 2019)
Personal pros: Direct patient care and stimulating environment. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse
Personal cons: High level of responsibility and intense situations requiring time in the operating room. Intense educational requirements.

Certified Nurse Midwife
A Certified Nurse Midwife provides care mostly to women of childbearing age. This includes prenatal checkups and delivery of noncomplicated births. They may also assist with family planning, prescribe birth control as well as treat both women and their partners who have been exposed to sexually transmitted diseases. (APRNS in the U.S.,2019) Payscale.com states that the average salary for a Certified Nurse Midwife is $93,047 per year. (payscale.com, 2019)
Personal pros: Hands-on patient care dealing with preferred population of women of childbearing age.
Personal cons: Specialty is very limited in patient population and needs.

Certified Nurse Practitioner
A Certified Nurse Practitioner is trained to diagnose and treat diseases of patients across the lifespan. They can also be responsible for health promotion, disease prevention and education of patients. They are authorized to diagnose, order tests and prescribe medications for the treatment of both chronic and acute illnesses. They may practice both independently and in collaboration with other healthcare providers if necessary. (APRNS in the U.S.,2019) The average salary for a Certified Nurse Practitioner is stated to be $90,829 per year. (payscale.com, 2019)
Personal pros: Wide patient population and the ability to provide both hands on patient care as well as collaborate with a wide team of professionals.
Personal cons: My state requires supervision of a physician for first 5 years of practice.
I chose to pursue my goal of becoming a Certified Nurse Practitioner after observing NPs in several work settings of mine. I first worked with them in home hospice, long term care and rehabilitation. Now I work with them in the acute care setting. I like that NPs have the option to work with many different patient populations compared to some of the other advance practice nurse specialties. I especially love the holistic perspective NPs that I have worked with tend to have and hope that I can provide that type of care for my own patients very soon. After graduation I intend to either work in mental health or women’s health. These are two areas of practice that hold special interest for me. I hope to do this in an outpatient setting. Currently, mental health would be my first choice. Having worked with many different nurse practitioners I have been aware of their scope of practice in my state for some time. This class has so far only intensified my desire to become a nurse practitioner. NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

References:

APRNS in the U.S. (2019). Retrieved November 6, 2019, from https://www.ncsbn.org/aprn.htm (Links to an external site.).

PayScale – Salary Comparison, Salary Survey, Search Wages. (2019). Retrieved November 6, 2019, from https://www.payscale.com/.

Collapse Subdiscussion Haley Allison

Haley Allison

Nov 7, 2019Nov 7, 2019 at 4:47am

Laura,

CNS also seems very impersonal to me, the ability to work with a patient and create a partnership to meet the patient’s health goals. I can see the value of the position, however it is not something I caould foresee myself doing for a career. I agree the nurse practitioner track has so many different opportunities built within the profession. It was one of the biggest factors that encouraged me to pursue this track over CRNA. I know everyone is different in what they have as professional career goals. That is nice that your state only mandates the first five years to be supervised, in Wisconsin we are required to have a constant relationship with an overseeing physician. It is so great that you have the drive and desire to work in mental health. That is something that there is a huge need for all across the country. What made you decide to pursue FNP over PMHNP if you know you want to do something with mental health? I look forward to your input throughout the class!

Best regards,

Haley

Collapse Subdiscussion Laura Leonard

Laura Leonard

Nov 10, 2019Nov 10, 2019 at 10:10pm

Hi Haley,

I chose FNP because of the versatility and the fact that I want a broad range of options. I find that mental health plays a large role in many other illnesses so I hope to always maintain a holistic approach regardless of the setting I end up working in.

Nov 8, 2019Nov 8, 2019 at 7:55am

Good, Laura. The CNP role does provide many opportunities, like you mentioned. It is important to assess careers in your area. While you are in clinicals, talk to your preceptor and ask how they like their position in that clinic, what hours they prefer, what their employer expects of them (patients per day, amount billed out, etc), and they may even give you insight into salary. This will help guide you when it comes time to look for your position and what to negotiate with potential employers.

Thank you for that advice! I do not remember enjoying clinicals during my first years in nursing school at all! I remember feeling very inadequate and shy around patients. I’m happy that those days and feelings are over and I’m actually looking forward to clinicals this time around. I still am not entirely sure about what setting I would like to work in when I graduate. I sometimes think I would like to work in an urgent care or primary care setting but I also have a passion for mental health. It seems that so many of the patients I care for at my current job have illnesses secondary to mental health issues yet we treat the physical ailments and send them home. According to the National Alliance on Mental Illness one in five adults suffer from mental illness. (NAMI, 2019) I have personally seen the negative effects of this in my own family and want to help make a change for those who suffer from it. I’m hoping that clinicals and the conversations you advise me to have with my preceptors will help me make my final decision.

References

NAMI. (n.d.). Retrieved November 11, 2019, from https://www.nami.org/learn-more/mental-health-by-the-numbers.

There are four roles an APRN can hold, a certified nurse practitioner (CNP), a clinical nurse specialist (CNS), a certified registered nurse anesthetist (CRNA), or a certified nurse midwife (CNM). The CNP can work in a multitude of environments that might include a physician’s office, a hospital setting, nursing homes, or work independently. They can work with any age range or can get a certification in a certain area like pediatrics. In the state of South Carolina, the practitioner must work under a physician’s license and that physician must be located within 45 miles of where the practitioner practices. With training in pharmacology scripts may be written but not scheduled 2 medications. Other restrictions are that home health and hospice cannot be ordered by the practitioner. The average salary for this position is $75,720 per year. The CNS is an advanced practice registered nurse who is a clinician with a higher degree of knowledge, skill, and competence. It requires a master’s degree with an emphasis in clinical nursing. Certain tasks that can be completed by the CNS, must be under physician’s supervision in the state of S.C. Their average salary is $97,638 per year. They, too, can work in the same types of environments and with all ages like the CNP however typically specialize in one area of medicine. The CRNA must successfully have completed an advanced organized formal CRNA education program at the master’s level accredited by the national accrediting organization of this specialty area and that is recognized by the board in S.C. They must be able to demonstrate advanced knowledge and skill in the delivery of anesthesia services. They must practice in accordance with approved written guidelines developed under supervision of a licensed physician or dentist or approved by the medical staff within the facility where privileges have been granted. They are typically employed in hospital operating rooms or outpatient surgical centers. They administer anesthesia for patients undergoing surgery or other medical procedures and work under the supervision of a physician. The average salary in S.C. for a CRNA is $128, 642 per year. The CNM is an advanced practice registered nurse who holds a master’s degree in the specialty area of midwifery. They must maintain an American Midwifery Certification Board Certificate, and they are trained to provide management of women’s health care from adolescence beyond menopause, focusing on gynecologic and family planning services, preconception care, pregnancy, childbirth, postpartum, care of the normal newborn, during the first 28 days of life, and the notification and treatment of partners for sexually transmitted infections. They can work in hospital settings or in physician office settings. They average a salary of $106,189 per year.

After doing research on the four different roles, it is hard to say if I would change my mind. I know I do not have a desire to administer anesthesia, I have always had an interest in midwifery however that does not seem to by a popular job in the area I currently reside so finding employment would likely be difficult. I feel like I will have the most opportunities with having the CNP, even though this is at the bottom of the pay scale among the four different possible roles. In the future I hope to move to another state where there is more freedom to practice. South Carolina always seems to be behind in healthcare and so there are limits on the independence of the CNP.

Reference:
Nurse Practice Act. South Carolina Code of Laws. Title 40 – Professions and Occupations. Ch 33, article 1. Section 40-33-10. Retrieved from www.scstatehouse.gov

Nicole Truslow

Nov 8, 2019Nov 8, 2019 at 7:59am

Great post, Nicole. Take a look at reimbursement rates across roles. Do you think the difference in reimbursement rates between the different roles is fair?

Collapse Subdiscussion Kimberly Logsdon

Kimberly Logsdon

Nov 6, 2019Nov 6, 2019 at 8:40pm

Professor Storms and Class,

The role of the advanced practice nurse stemmed from the rising need for providers. The aging population, high prevalence of chronic illness, and the enactment of the Affordable Care Act have led to an increase in the demand for primary care that the current supply of primary care providers may be unable to meet (Poghosyan, Norful, & Martsolf, 2017). The four advanced practice nurse roles include, certified nurse Midwife (CNM), certified nurse practitioner (CNP), clinical nurse specialist (CNS), and certified registered nurse anesthetist (CRNA). Each of these roles consist of unique responsibilities, work environments, level of accountability, diverse patient populations, salary, and scope of practice.

Certified nurse-midwives hold national certification and state licensure to practice in all 50 states, but the scope of practice varies in each state. Some CNMs are paid on a per-birth basis, while others are salaried workers employed by hospitals, clinics, birthing centers, and other organizations specializing in primary or reproductive healthcare. They may even offer services in homes. The average Midwife salary in the United States is $107,529 as of October 30, 2019, but the salary range typically falls between $94,077 and $125,717 (Midwife Salary in the United States, 2019) .

Pros for becoming a CNM are earning a decent income, working with a specialized patient population, earning a substantial income, promoting more natural births for patients, practicing holistic philosophy of care that emphasizes a more natural approach to childbirth, and can spend more one-on-one time interacting with their patients than a physician can during appointments and prenatal visits. They also provide more hands-on support during labor, birth and postpartum. Cons to being a CNM are the inability to perform a C-section if a pregnant woman needs one, inability to care for high risk pregnancies, and being on-call for deliveries. Some health insurance plans may not reimburse for midwife services that occur outside of a hospital setting such as home births.

Nurse practitioners have full independent practice authority in the state of Iowa. NPs are recognized in state policy as primary care providers in Iowa, but may also hold hospital admitting privileges. In Iowa, an ARNP may provide healthcare services to Iowans of all ages in primary and/or ambulatory, acute, and long-term settings. The ARNP practices within their scope of practice based upon their educational background and the standards and guidelines established by their national certifying body such as American Nurses Credentialing Center or American Academy of Nurse Practitioners. In Iowa, an ARNP may practice independently. However, an ARNP may have a collaborative agreement with a physician or physicians if their practice so warrants, but this agreement is not a requirement of the Iowa Board of Nursing.

Pros for becoming a CNP in Iowa include gaining full practice authority, income, alleviating the primary care crisis, and providing a cost-efficient means of supplying hands-on care (Hain & Fleck, 2014). Cons include some insurance companies still require billing under a physician name or may reimburse nurse practitioners at lower rates. The average Nurse Practitioner salary in the United States is $107,850 as of October 30, 2019, but the range typically falls between $100,074 and $117,158 (Nurse Practitioner Salary in the United States, 2019).

A clinical nurse specialist (CNS) is responsible for assessing a healthcare facility’s nursing practice and its impact on patient outcomes. The CNS provides clinical direction to nursing staff in the delivery of patient care programs, ensures nursing staff maintains an established level of clinical competency. The CNS requires a master’s degree at minimum, and typically reports to a manager or head of the department. The CNS manages subordinate staff in the day-to-day performance of their jobs. The CNS ensures that department goals are met and that the department adheres to approved budgets. The CNS scope of practice includes direct patient care services, as well as staff education and macrosystem management of a specialized population, embedded within a nursing or a system model.

Pros for becoming a certified nurse specialist include the ability to work in a variety of settings, substantial income, promising job outlook, ideal working hours, and flexibility to enroll in online education programs. Cons include the lengthy amount of time spent in school and the expensive college tuition. The average clinical nurse specialist will earn an annual income of $101,276 to $120,000.

A certified registered nurse anesthetist (CRNA) is an advanced practice registered nurse who administers anesthesia and other medications. They also monitor patients who are receiving anesthesia, and recovering from anesthesia. CRNAs must hold minimum of a master’s degree focusing on anesthesia. They must complete extensive clinical training, and pass a certification exam approved by the National Boards of Certification and Recertification of Nurse Anesthetists (NBCRNA). CRNAs care for patients of all ages. Some of their patients are scheduled procedures, and others are emergent surgeries.

Pros to becoming a CRNA is the ability to work with various ages of patients, lucrative income, and promising job outlook. Many nurses who chose this specialty also enjoy the fact that their patient is asleep during procedures. Cons to this specialty include having to be on-call, extensive education program, and expensive tuition. Many CRNA programs require applicants to have one year of experience working in an intensive care unit or an emergency department prior to being accepted into the program. The U.S. Bureau of Labor Statistics (BLS) noted that in 2016, CRNAs made between $105,400 to $242,000, with the average annual salary being approximately $157,000 (nurse.org, 2019).

I chose to become a family nurse practitioner due to the desire to care for patients and families during their time of need. I originally wanted to become a physician, but I didn’t have the desire to be in school for eight years plus residency. Family nurse practitioners have the flexibility to work in a variety of healthcare settings, while earning a substantial income. In the state of Iowa, nurse practitioners are allowed to practice independently, which means they can open their own practice or work in collaboration with another healthcare professional. The Affordable Care Act provided many people with insurance, allowing access to healthcare. This created a large demand for primary care providers, therefore creating a positive job out look for nurse practitioners. Researching the scope of practice for nurse practitioners in Iowa, has reaffirmed my desire to become a family nurse practitioner. After graduation, I plan to gain experience by working in an urgent care setting. Once I have enough experience and feel competent, I may decide to open an independent practice.

Kim Logsdon

References

Hain, D., & Fleck, L. M. (2014). Barriers to NP practice that impact healthcare redesign. the Online Journal of Issues in Nursing. doi:10.3912/OJIN.Vol19No02Man02

Midwife Salary in the United States. (2019). Retrieved from salary.com: https://www.salary.com/research/salary/recruiting/midwife-salary

Nurse Practitioner Salary in the United States. (2019). Retrieved from salary.com: https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary

nurse.org. (2019). Retrieved from Nurse Anesthetist: https://nurse.org/resources/nurse-anesthetist/

Poghosyan, L., Norful, A. A., & Martsolf, G. R. (2017). Primary care nurse practitioner practice characteristics. Journal of Ambulatory Care Management. doi:10.1097/JAC.0000000000000156

Nov 8, 2019Nov 8, 2019 at 8:06am

Kim, urgent care settings do give you a variety of illnesses and can give that adrenaline rush too. Something to also consider, especially if you end up opening your own practice is getting at least a year in family practice right out of school. You will see acute illnesses and chronic diseases to get a broad foundation to build upon. I know many NPs who come out of school and go right into an urgent care setting. A couple years later they decide to go into family practice and struggle because they haven’t been using the knowledge from school and applying it to chronic conditions. They all say they wish they had started in family practice and then branched out to acute care or specialty. We have a new nurse practitioner in our office. She has been working in urgent care for 7 years and now is in our family practice. She is so lost and has forgotten even normal cholesterol levels, basic meds, and first line treatments for common chronic diseases. She tells me every day that she regrets not getting the first year of foundation in family practice because she forgot a lot. The same goes for a nurse I went to NP school with. She did urgent care for 1.5 years and then went into family practice and she struggled. She is better now of course but it took her a year to get all the basics down again, and it took a lot of studying to refresh. Do what will make you happy, that should come first! Talk to your preceptors too and get their opinions and thoughts. They can be great guides through school and getting started in your career.

Collapse Subdiscussion Priscilla Phelps

Priscilla Phelps

Nov 6, 2019Nov 6, 2019 at 8:42pm

Greetings all,

For Advanced Practice Nurses (APNs) there are four different roles: Certified Nurse Midwife (CNM), Certified Nurse Anesthetist (CRNA), Clinical Nurse Specialists (CNS), and Nurse Practitioner (NP). Certified Nurse Midwives work primarily within a health system which allows for consultation, referral, and patient care management. CNMs in Oklahoma are accountable to the OK Board of Nursing and to their supervising physician. The patient population typical of CNMs includes normal newborns, antepartal, intrapartal, and postpartal women, and other women needing gynecological care (Oklahoma nursing practice act, 2019). CNMs provide general gynecological and preventative care, as well as assess, educate, and manage birth control methods, and assist normal, uncomplicated deliveries (Oklahoma nursing practice act, 2019). The average salary for a CNM in Oklahoma ranges from $94,075 to $115,934 annually (salary.com (Links to an external site.), 2019). For me, personally, while a CNM has the opportunity to work with families in some of their most joyful times, I did not enjoy the Labor and Delivery rotation in my undergraduate study.

Certified Nurse Anesthetists work primarily in the Operating Room, Labor and Delivery, or Dental environments and administer Schedule II-V medications, gases, and initiate advanced airway devices in the perioperative or periobstetrical periods only (Oklahoma nursing practice act, 2019). CRNA patients include perioperative or periobstetrical patients of all ages. CRNAs in Oklahoma are accountable to the OK Board of Nursing as well as the physician or dentist consulting on-site. CRNAs in Oklahoma have the greatest salary potential of all APRN roles ranging from $158,481 to $188,120 (salary.com (Links to an external site.), 2019). Of course this higher pay is an enticing benefit, however, CRNAs in Oklahoma typically use an on-call scheduling in addition to regularly scheduled hours which can disrupt time off.

Clinical Nurse Specialists can work in virtually any setting – acute care, in-patient care, long-term care, therapeutic care, or primary care, just to name a few. In addition to research and education roles, CNSs are responsible for assessments, performing and interpreting diagnostic or laboratory tests, diagnosing, managing treatments through the coordination of care, and counseling patients and families (Oklahoma nursing practice act, 2019). CNSs are accountable to the OK Board of Nursing as well as their supervising physician. CNS patient populations are specialty specific and covers the full lifespan. CNS salary in Oklahoma ranges from $89,620 to $108,575 (salary.com (Links to an external site.), 2019). Some benefits to working as a CNS include working in a familiar environment like a major hospital and the possibility of working 8 hour days instead of 12 hour days. Working in a major hospital, however, brings a more collaborative role and having to deal with hospital administrators which can be a frustratingly delicate balance.

Nurse Practitioners in Oklahoma can also work in any setting, including private practice with a supervising physician and are accountable to the OK Board of Nursing and their supervising physician (Oklahoma nursing practice act, 2019). NP patients are specialty specific and can cover the lifespan. In addition to the scope of the CNS, NPs can prescribe and manage Schedule III-V medications with a supervising physician (Oklahoma nursing practice act, 2019). Typical NP salaries in Oklahoma range from $94,070 to $110,129 (salary.com (Links to an external site.), 2019). Working as a NP in Oklahoma offers independence with operating a private practice under a supervising physician (aanp.org (Links to an external site.), 2019). Additionally, with added training I can work in acute care settings like urgent care centers and Emergency Departments. Perhaps the biggest negative aspect of working as a NP in Oklahoma is paying the supervising physician, which can be close to $1,000 per month.

After graduation, I plan to work in the acute care setting, primarily in a free-standing urgent care, for a few years and then open a private practice. Independence and opportunity to own a practice are the driving factors in choosing the NP role. The decision to pursue an APRN resulted from heavy research and prayer, therefore the overall impression of NP practice in Oklahoma has not changed for me.

References

aanp.org. (2019). Scope of Practice for Nurse Practitioners. Retrieved November 6, 2019, from https://www.aanp.org/advocacy/advocacy-resource/position-statements/scope-of-practice-for-nurse-practitioners.

Oklahoma nursing practice act. (2019, June). Retrieved October 28, 2019, from http://www.nursing.ok.gov/act4.html.

Salary.com. (2019). Certified Nurse Midwife Salary in Oklahoma. Retrieved November 5, 2019, from https://www.salary.com/research/salary/benchmark/certified-nurse-midwife-salary/ok (Links to an external site.).

Salary.com. (2019). Certified Nurse Anesthetist Salary in Oklahoma. Retrieved November 5, 2019, from https://www.salary.com/research/salary/benchmark/certified-nurse-anesthetist-crna-salary/ok (Links to an external site.).

Salary.com. (2019). Nurse Practitioner Salary in Oklahoma. Retrieved November 5, 2019, from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/ok (Links to an external site.).

Salary.com. (n.d.). Clinical Nurse Specialist Salary in Oklahoma. Retrieved November 5, 2019, from https://www.salary.com/research/salary/benchmark/clinical-nurse-specialist-salary/ok (Links to an external site.).

Nov 8, 2019Nov 8, 2019 at 8:08am

Good, Priscilla. Some states are requiring that in order to work in a hospital or acute care setting as an NP you have to have acute care certification, like an Acute Care NP. How do you feel about this consideration?

Collapse Subdiscussion Priscilla Phelps

Priscilla Phelps

Nov 8, 2019Nov 8, 2019 at 9:45pm

Professor Storms,

Acute care certification is required in Oklahoma in order for a Nurse Practitioner (NP) to work in an Acute Care. I plan to also take this exam soon after passing my boards. Personally, I think adding this certification requirement is of great benefit to the state. I work for a Helicopter Air Ambulance and in addition to running scene calls with rural EMS agencies, we also provide critical care transport from rural hospitals to the larger city hospitals. In this field, I have seen firsthand the importance of having a competent and qualified acute care professional in these rural areas with limited providers. Having this extra requirement and certification brings greater competency and skill to a critical care practice that perhaps would not otherwise be encouraged except through personal drive. It does not guarantee perfect care in all situations but no degree or certification can accomplish that. It does, however, bring greater consistency in care which is crucial in these rural areas with limited providers.

Collapse Subdiscussion Kathleen McGrath

Kathleen McGrath

Nov 10, 2019Nov 10, 2019 at 10:56am

Priscilla,

I think you did a really nice job discussing each of the various roles as advanced practice nurses. I agree that while a CNM is present for many happy occasions, however, it was not an area that I enjoyed spending time in while in school. The role of certified nurse anesthetist is one that I think is rapidly growing, but I agree about the potential to interrupt time off by being on call. This can cause an interference with the work life balance that is very important in this career. While it is a crucial role, it is one that does not involve a significant amount of patient interaction and thus it was not a role that I was very interested in. One thing that I was not previously aware of was that you mentioned that nurse practitioners may have to pay the supervising physician up to $1,000 a month to practice. This was very surprising to me and I am now dedicated to finding more information on if this is true within the state of Illinois as well. I have also thought intermittently about pursuing an additional acute care certification but think that it is first best to pursue a degree as a family nurse practitioner and to focus on providing comprehensive outpatient care. Having worked in both inpatient and outpatient, I have found that there is often a disconnect between providers and I want to be a provider that helps coordinate patient’s care and provide a seamless transition from hospital to home.

Kathleen

Collapse Subdiscussion Priscilla Phelps

Priscilla Phelps

Nov 10, 2019Nov 10, 2019 at 5:07pm

Kathleen,

Thank you for your response. Perhaps like you, I also did not enjoy the Labor and Delivery rotation in school. I liked the technical application of the tonometer and diagnosing early and late decelerations and their implications and pathophysicology, but I decided during that rotation that Labor and Delivery was not where I wanted to practice. The nurse anesthetist role, as you pointed out, does not typically involve a lot of patient interaction which, initially, intrigued my little introverted heart. But, in a role like that I felt I would quickly become bored. The Nurse Practitioner role intrigues me the most because it seems to have the greatest flexibility. What I mean is that I could continue to work in acute care and feed my adrenaline rush as well as challenge my critical thinking skills, or I could move to primary care and help to manage chronic diseases, or work in a more rehabilitative role in improving functionality and wellness in a wide range of patient ages and conditions.

In talking with several nurse practitioner friends in Oklahoma, the high expense of maintaining a collaborative agreement with a supervising physician is bitter sweet. The downside is the high cost, typically around $1,000 per month, however, the upside is it does not seem to be a hard sell to find a willing physician to collaborate with. I agree that often there is a disconnect between discharge and follow-up and having a skilled NP to help with that transition I think is an invaluable tool and I wish you all the best!

Rashelle

Collapse Subdiscussion Melissa Stone

Melissa Stone

Nov 6, 2019Nov 6, 2019 at 10:20pm

CNP: Certified Nurse Practitioners are graduate level educated and are able to practice independently in a wide range of settings. According to ncsbn.org, CNPs are responsible for health promotion, disease prevention, and education. CNPs also provide diagnosis and management of diseases. Their patient population ranges from family practice, pediatrics, geriatrics, internal medicine and women’s health. CNPs can specialize as primary care NPs or acute care NPs, which have separate certifications. According to the Bureau of Labor Statistics the mean annual wage of a CNP is $110,030. This specialty allows the CNP to practice in numerous different settings and scope of practice is determined by the state the NP will practice in.

Pros: wide variety of places to practice, can see patients of all ages or choose a specialty, practice independently depending on state

Cons: May have restrictions to practice depending on state

CNS: The Clincial Nurse Specialist is graduate level educated and cares for patients across the care continuum. They must possess a master’s or doctorate degree in nursing. According to the National Association of Clinical Nurse Specialists, the CNS is an expert clinician with training in a specialized area of nursing practice defined by population, setting, disease, type of care, or type of problem. The CNS must obtain certification based on a population area such as adult, pediatrics or neonatal. Administrative rules for practice are determined by state. The CNS helps bridge the gaps and help improve patient care. According to the Bureau of Labor Statistics, the average annual salary for a CNS is $104,630.

Pros: can work in a very specific area of nursing, demand for the role is increasing

Cons: less direct patient care, may work in high risk areas

CRNA: Ncsbn.org recognizes the Certified Registered Nurse Anesthetist as an advanced practice registered nurse that is able to provide care for a wide variety of patients. CRNA’s are responsible for anesthesia care for a number of procedures and surgeries. CRNA’s care for patients across the entire lifespan and of all health statuses. According the American Association of Nurse Anesthetists, CRNAs work in every setting in which anesthesia is delivered including hospital surgical suites, delivery rooms, ambulatory surgical centers, dentist offices and plastic surgeons. According the Bureau of Labor Statistics the mean annual wage of CRNAs is $169,450.

Pros: very specific type of work, different patient populations

Cons: rigorous course work, less face to face interaction with patients

CNM: The Certified Nurse Midwife provides many services to women across the lifespan. CNMs are independent healthcare providers. The services that a CNM provides includes gynecologic care, prenatal and postpartum care, childbirth and newborn care. The CNM provides treatments for a wide variety of reproductive health issues. The American College of Nurse Midwives recognize other responsibilities of the CNM as attending births, annual exams, writing prescriptions, patient education and reproductive health visits. The CNM can practice in a hospital, clinic, freestanding birth center, or patient homes. The mean annual wage for CNMs is $106,910.

Pros: very rewarding, wide scope of practice, variety of patients

Cons: varied hours, high risk situations

I chose the Certified Nurse Practitioner role as I feel that this is one of the most diverse APN roles out of the four. There are many options to choose from when it comes to clinical practice. Being able to specialize in something I enjoy is important. There is diversity in the type of setting and patient population when it comes to choosing the CNP role. For example, the CRNA has a standard way that they care for patients, which is provide types of anesthesia. In the future I would like to practice as an NP either in an urgent care or women’s health. Coombs (2015), recognizes that the ability of the NP to practice is largely dependent on the individual state’s scope of practice.

References

American College of Nurse-Midwives. (n.d.). Retrieved November 2019, from http://www.midwife.org/.

APRNS in the U.S. (n.d.). Retrieved November 2019, from https://www.ncsbn.org/index.htm (Links to an external site.).

Become a CRNA. (2019, November). Retrieved from http://www.aana.com/ (Links to an external site.)

Coombs, L. (2015). The growing nurse practitioner workforce in specialty care. The Journal for Nurse Practitioners, 11(9), 907-909. doi:10.1016/j.nurpra.2015.06.014

National Association of Clinical Nurse Specialists |. (2019, November). Retrieved from https://nacns.org.

U.S. Bureau of Labor Statistics. (2019, November). Retrieved from https://www.bls.gov.

Nov 7, 2019Nov 7, 2019 at 7:45pm

Good Evening

Melissa,

Your post was very interesting to me. It appears that no matter the state, the CNS appears to have the lower salary. Which state were are you located in? There is a big difference in the CNS salary in Texas and as little as $72,890 and the CNM’s Annual Wage of $85,900. There are no changes in the responsibilities and preparation as far as education that would justify such a big gap in compensation. I did not personally choose to become a CNP due to the amount of money that I would be paid; however, I do think that if these advanced professionals are credentialed and practice expectations are aligned across the board, then there should be fair compensation. There are differences in skill sets and competencies across practices and disciplines which makes drawing the line a little difficult. It is understood regardless that one should be acknowledged well beyond the Baccalaureate level of practice as well. When I graduated from college in December 2000, some of my classmates were already making $50 dollars an hour in Houston, Texas. That was 19 years ago.

– Kelda

Collapse Subdiscussion Melissa Stone

Melissa Stone

Nov 10, 2019Nov 10, 2019 at 4:17pm

Kelda,

After reading your post as well, it seems like there are some differences as well as similarities across states. I live in Illinois, but it does seem as though the trend is the CNS salary is lower across the board and of course the CRNA salary is the highest. It is very interesting to see the differences in scope of practice, authority, and salary across many states. I do agree about the compensation of all the roles, however I do know how rigorous CRNA school can be and just how difficult it is to even get into a program as I personally explored this option for myself. After completing this assignment I think it gave me a very good idea of the other specialties and I’m glad I chose the CNP role. I think many of us are apprehensive about our future roles and we just hope to be able to fulfill them the best we can. I hope this brought some peace of mind to you, as well as all the other students as it did me.

Nov 8, 2019Nov 8, 2019 at 8:13am

Great, Melissa. The NP role is a great one and will provide you with a wide knowledge base, direct patient care, and still have time with family. It gives you many options, you can work anywhere, and if you get tired of one type of practice you can go into another type of practice without having to go back to school to obtain another degree. It helps provide a great foundation of knowledge and you never get bored as you will see such a variety of patients and conditions. I have to say I am happy I chose it and I think you will be satisfied as well.

Nov 10, 2019Nov 10, 2019 at 7:44pm

Melissa,

I read your post, and it was very intriguing. When I noticed you mentionned about working in urgent care when you completed your FNP, it triggers to investigate more about NPs working in that setting. There are significant benefits to working in urgent care. It is a good way any NP can get an amazing education that prepares them for a wide variety of scenarios down the road. Cerruti (2016) has documented that nurse practitioners who worked in urgent care clinic at least for six years and are trained by emergency physicians at least of 20 years of experience. These nurse practitioners are found to grow professionally in ways she hadn’t imagined.

Additionally, the speculation is that urgent care clinics nurse practitioners can make a significant difference for the patients they see. The FNPs have explained that having a smile and taking the time to be extra thorough made all the difference in the world. It is explained that the urgent care clinic’s patient-centered approach also means that the NPs are likely to be working with patients on financial decisions. It is proven that many patients choose urgent care clinics over emergency rooms because they’re being cost-conscious. As a future FNP you will be looking at the necessity of tests and the costs of X-rays, labs, and other options. In this situation the FNPs will be helping these patients to find creative solutions can be very rewarding (Cerruti, 2016).

Researchers have shown that the working in the emergency room can provide a big adrenaline rush, but such high-stress work can also lead to burnout over time. Urgent care clinics have a slower pace that can be a better match for some personalities. It is proven when health care communication interviewed NPs who switched from working to ED to urgent care and found they were generally happy with their decision. In the standardized urgent care environment. Overall, working in urgent care can be a very rewarding experience for a nurse practitioner. You’ll have an opportunity to work on a variety of ailments, but with less stress and fewer (Cerruti, 2016).

References

Cerruti Dellert, J. (2016). Reading between the lines: A Book Review. Pediatric emergent/urgent and ambulatory care: The pocket NP — A Quick reference resource for ENPs. Pediatric nursing, 42(3), 155. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=ehh&AN=116249517&site=eds-live&scope=site (Links to an external site.)

Nov 6, 2019Nov 6, 2019 at 10:33pm

https://www.nursinglicensure.org/np-state/texas-nurse-practitioner.html#foci (Links to an external site.)

Week 2: Advanced Practice Nursing (Texas)

Dr Storms & Class,

In this week’s discussion, we explored the four (4) main APN categories of advanced nursing practice for the State of Texas, Pro’s and Con’s related to each area of practice, my rationale for choosing the CNP advanced practice role over the other three APN designations, what my clinical plans following graduation, and whether my ideas of NP has changed after researching my state of future FNP practice.

Work Environments

The CNS (Clinical Nurse Specialist) works in multiple environments within the hospital system, as a mentor, change agent for support of system and evidence-based practices, diversity within the workplace and as a patient advocate when clinical and ethical decision making is needed.

The CNP (Certified Nurse Practitioner) may work within a Family Practice, Pediatrics care clinic, Internal Medicine, Geriatrics, Women’s healthcare center, or Urgent Care Settings.

The CNM (Certified Nurse Midwife) work environment of the CNM can include a patient’s home, birthing center, the hospital, ambulatory care settings, private offices, community or public health clinics.

The CRNA (Certified Registered Nurse Anesthetist) works in multiple settings to include ambulatory surgery centers, hospital operating rooms, trauma/ stabilization units, as well as, military, pain management, dental, ophthalmology, podiatry and plastic surgery clinics.

Scope of Practice, Level of Accountability & Population

All of the practice(s) of the APN Scope of Practice is regulated by the Nurse Practice Act of Texas and limited practice under the State of Texas. The APN does not practice independently of Physicians and should practice according to individual advanced practice skills and competencies.

The CNS is accountable for diagnosis and treatment of health or illness related disease management and health promotion or prevention. They address risk behaviors that extends out to beyond individual patients to families and groups. Unlike the CNS, the CRNP (Certified Registered Nurse Practitioner) and CNM (Certified Nurse Midwife) under the agreement with a Physician and under a supervising Physician during practice, are responsible for initial, ongoing, comprehensive exams (ie. Physical Exams and Health Assessments), interpretation of labs, Screenings or orders for health related screenings and/or labs & imaging studies. Responsibilities expand across the lifespan for patients for the CNP that may be well or , present with acute, multiple illness, symptoms, or chronic disease diagnoses. The primary focus of responsibilities of the CNM are women throughout their lifespan, gynecologic care, family planning, preconception care, prenatal and postpartum care, or childbirth and the care of the newborn. The CNM’s expertise extends to the male partner of the patient to address STD’s and reproductive health. The CRNA is accountable to practice in a variety of settings to include assessment and interventions of the APN to apply critical skills that may be invasive or non-invasive in nature. The CRNA is responsible for pre/ post anesthesia assessment or recovery of patients across the lifespan, critical or acute care of the patient being stabilized or undergoing anesthesia; including nerve blocks.

Salary

According to the Bureau of Labor Statistics for Texas (2016) of each advanced nurse professional researched within the State of Texas, the CRNA was the highest paid advanced practice nurse with an annual mean wage of $158,510. Mean hourly wages were $76.21 dollars per hour. Next on the list from highest paid to least, the CRNP averaged an Annual Mean Wage of $158,510; with mean hourly wages of $52.24 dollars per hour. Followed by the CRNP, the CNM’s Annual Wage Means were $85,900; with Mean hourly wages of $41.30 per hour. Last, but certainly not the least of professions, was the CNS which was not found on the list; however, through further inspection of the site and inquiry, surprisingly, was grouped with the Registered Nurses. Clinical Nurse Specialists (CNS) were depicted to have an Annual Mean Wage of under $72,890 dollars; or $35.04 mean hourly wages.

Pros and Cons

Personally, I respect each are of advanced nursing practice and understand the work , commitment, and drive that one has to have to complete and continue within the necessary requirements for licensure and/or endorsement as a lifelong learner and professional. I will start with at least one Pros for each role as it pertains to future goals. According to the regulatory bodies of the Texas State BON and Nurse Practice Act, each of the disciplines require formal education from an accredited university at the master’s level and beyond according to his/ her individual abilities which is a plus and definitely what one should look for when seeking national certification and proof of competency as an advanced practice nurse.

TX APN > Pros

CNP – Practice across Lifespan

CNS – Similar to CNP role

CNM – Ability to practice in non-clinical setting (ie. patient’s home).

CRNA – Invasive / Critical Care Skills

TX APN > Cons

CNP – Prescriptive authority under Physician. Not true for other states.

CNS – Lowest paid APN role in Texas (Bureau of labor Statistics Texas, 2016).

CNM – Limited to women and to little support of male patient. AMCB

board exam certification required, (Nursing Licensure.org, 2013-2019).

CRNA – Rigorous education preparation; certification / training

requirements for pain management.

Rationale for CNP Practice

The reason that I chose to practice as a Certified Nurse Practitioner over the other three APN professions was that the focus is on preventative health; as well as, comprehensive care of the total patient. Most of the APN practices, besides the CNM are focused on patients with symptoms and/or illness that require treatment through acute care and diagnosis. Very rarely are they afforded the opportunity to establish a relationship with the patient. The CNP can address the lifespan of the patient in a holistic way to include prevention of diseases or unhealthy lifestyles that may influence health and safety risks. The CNP acts as an advocate and leader which refers the patient to adjunctive health disciplines when needed (ie. mental, physical rehab, etc.). The CNP is in the best position to engage the patient and family in their individual plan of care, educate, and to build ongoing relationships with the patient and communities served. After researching these APN roles, my opinion has not changed of my choice in career. If anything, it has been strengthened through the knowledge gained.

References

Advanced Practice Registered Nurse License Requirements in Texas (2013-2019). Retrieved from

Bureau of Labor Statistics (2016). Retrieved from

https://www.bls.gov/oes/current/oes_tx.htm (Links to an external site.)

Texas Board of Nursing: Laws & rules – Nursing practice act

Retrieved from http://www.bon.texas.gov/laws_and_rules_nursing_practice_act.asp (Links to an external site.)

Texas Board of Nursing: Practice – Advanced practice information

Retrieved from http://www.bon.texas.gov/practice_nursing_practice_aprninfo.asp (Links to an external site.)

Nov 6, 2019Nov 6, 2019 at 10:37pm

https://www.nursinglicensure.org/np-state/texas-nurse-practitioner.html#foci (Links to an external site.)

Addenda to above posting due to formatting issues.

Week 2: Advanced Practice Nursing (Texas)

Dr Storms & Class,

Work Environments

The CNP (Certified Nurse Practitioner) may work within a Family Practice, Pediatrics care clinic, Internal Medicine, Geriatrics, Women’s healthcare center, or Urgent Care Settings.

Scope of Practice, Level of Accountability & Population

Salary

Pros and Cons

TX APN > Pros

CNP – Practice across Lifespan.

CNS – Similar to CNP role.

CNM – Ability to practice in non-clinical setting (ie. patient’s home).

CRNA – Invasive / Critical Care Skills.

TX APN > Cons

CNP – Prescriptive authority under Physician. Not true for other states.

CNS – Lowest paid APN role in Texas (Bureau of labor Statistics Texas, 2016).

CNM – Limited to women and to little support of male patient. AMCB board exam certification required, (Nursing Licensure.org, 2013-2019).

CRNA – Rigorous education preparation; certification / training

requirements for pain management.

Rationale for CNP Practice

References

Advanced Practice Registered Nurse License Requirements in Texas (2013-2019). Retrieved from

Bureau of Labor Statistics (2016). Retrieved from

https://www.bls.gov/oes/current/oes_tx.htm (Links to an external site.)

Texas Board of Nursing: Laws & rules – Nursing practice act

Retrieved from http://www.bon.texas.gov/laws_and_rules_nursing_practice_act.asp (Links to an external site.)

Texas Board of Nursing: Practice – Advanced practice information

Retrieved from http://www.bon.texas.gov/practice_nursing_practice_aprninfo.asp (Links to an external site.)

Reply Reply to Comment(1 like)

Nov 8, 2019Nov 8, 2019 at 8:16am

Kelda, great information. Holistic care is a big factor in NP practice. What is the difference between naturopathic care and holistic care?

Nov 9, 2019Nov 9, 2019 at 8:32pm

Dr Storms,

We were taught that the Holistic care of the patient in Nursing has always been thought to be the inclusion of the nurturing and care for the total patient in view of his or her individual, health, emotional, spiritual, mental or physical needs. In my opinion, these are pretty close in the effects on the patient; however, use of resources and economical attributes become a different matter as the naturopathic application may be more widely considered as a means to address health in a way to let the body heal itself through use of I believe nutrition or hydrotherapy or techniques that could bring about healing and health promotion or illness prevention without application of medicine. I would think that medicine is often utilized to holistically take care of a patient with clinical depression in order to address the total health of the patient and allow them to work and provide financially for their family.

– Kelda

Collapse Subdiscussion Kathleen McGrath

Kathleen McGrath

Nov 6, 2019Nov 6, 2019 at 11:12pm

Class,

In researching all of the different types of advanced nursing degrees, I found that within the state of Illinois there were many similarities between scopes of practice. According to multiple sources, nurse practitioners must practice under a collaboration with a physician. CNPs, CRNAs and CMPs are able to prescribe schedule II- V controlled substances within the state of Illinois. CNPs can focus on a variety of different specialties, however I chose the role of a family nurse practitioner. The family nurse practitioner has a wide patient population and can see individuals throughout the life span from toddler to elderly. Some positives about this role is that it allows for a wide range of patients and conditions and offers many career opportunities. The cons associated are that family nurse practitioners are typically limited to out-patient areas. The salary for this role is generally around $110,000.

The CRNA works with general anesthesia, local anesthesia and pain management. These advanced nurses can work both in a hospital as well as in an outpatient procedural center. CRNAs can work with all ages from newborn to elderly. Similar to the CNP, these nurses must enter into a collaborative agreement with a physician. Pros associated with this career include that these nurses can do shift work meaning they may have more flexible hours and they work with a variety of ages. They are also highly paid. Cons include less patient interaction compared to other nursing specialties and the fact that it can be a very high stress, demanding role. In Illinois the average CRNA makes $194,000.

Certified nursing specialists are masters level nurses who focus on evidence-based nursing and often work to influence healthcare on a systemic level. These nurses may be involved within a hospital setting to train nurses as well as to help coordinate care and work on hospital wide quality improvement. According to one source, the average salary for this role in the city of Chicago is $111,000.

CNMs also have the same limitations as other advanced practice nurses in the US in terms of collaboration and prescribing abilities. These nurse midwives assess and diagnose, order therapies and tests, interpret results and can also provide counseling to women or palliative support (2019). The pros related to this position is that many positive encounters are made when helping bring new life into the world. These nurses develop close relationships with patients and encourage patients to promote the natural birth process. The cons are that it includes only one type of patient and may be self- limiting in terms of job opportunities.

I chose the CNP and more specifically, FNP program because I have always wanted to play a more active role in decision making for my patients. I am intrigued by disease processes and taking data from tests and labs and using this information to make a plan for my patients. I work with many NP in my current role and I find the NP role to be super valuable to patients. I am very invested in taking my bedside experience in holistically treating patients and implementing this into my own practice. I chose the family nurse practitioner route because I believe that it provides me with the most options in terms that it covers a vast array of ages and I think it is beneficial to my own learning to be exposed to a variety of diseases and illnesses. I am unsure of my exact clinical plans post-graduation. I work very closely with several nurse practitioners in the heart center at my hospital. The heart center is a group of nurse practitioners and physicians who work with children after heart transplants to follow up on their medical needs. This is something that I am very interested in. Having not had any clinical experience, however, I am open to other areas and avenues to explore. My biggest take away from researching these four different advanced degrees is that there are so many areas that nurses can take if wanting to pursue advanced education. Nurses have the ability to have a more direct role in managing patients through the roles of CNP, CNMs and CRNAs and also have the ability to affect practice changes throughout healthcare systems as clinical nurse specialists. According to a study about the transition of family nurse practitioners into practice, the authors call for a smooth transition that instills confidence in the advanced nurse practitioner to provide services as primary care providers to fill the current and expected gap (Dumphy, 2019). This week’s lesson discussed the need for nurse practitioners to be high in skill, understanding of both the disease process as well as the patient’s feelings about the disease and lastly, the ability to integrate the knowledge learned with clinical judgement and assessment to provide the best overall care.

References:

Dumphy, D., DeSandre, C., & Thompson, J. (2019). Family nurse practitioner students’ perceptions of readiness and transition into advanced practice. Nursing Forum, 54(3), 352–357. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1111/nuf.12336

Nurse Practitioner Salary in Illinois. (2019, October 30). Retrieved from https://www.salary.com/research/salary/benchmark/nurse-practitioner-salary/il.

Online Midwifery Schools Offering CNM Masters Degrees in Illinois. (2019). Retrieved from https://www.midwifeschooling.com/illinois/.

What is a Clinical Nurse Specialist (CNS)? (2019). Retrieved from https://www.msnedu.org/clinical-nurse-specialist/.

Nov 8, 2019Nov 8, 2019 at 8:18am

Kathleen, feeding off of the question I asked Kelda and since you mentioned holistic care…There is a difference between holistic care and naturopathic care. Let’s say that you have a patient seeking naturopathic care but her cholesterol is through the roof! She declines any prescriptions and only wants to take herbal remedies. What would your approach to this patient be?

Collapse Subdiscussion Kathleen McGrath

Kathleen McGrath

Nov 9, 2019Nov 9, 2019 at 2:19pm

Hi Dr. Storms,

I think providing holistic care is important both within in patient as well as out patient settings. My definition of holistic care would be to provide care that focuses on the entire patient experience. Throughout my years as a nurse I have found that often we are treating not only the patient’s physical ailment but also their psychological and spiritual health as well. Knowing what is important to a patient is important to deciding how to best care for them. Naturopathic care, on the other hand, is when a patient chooses a more natural form of medical interventions and these patients typically focus on herbal remedies and treatments. In these types of patients I think it is important to listen to their medical wishes but to also educate them on the benefits of taking a medication, in this case, to lower cholesterol. Coming up with a compromise could also be beneficial. In this case, one could suggest to the patient to begin taking a medication for high cholesterol while also changing one’s diet and implementing more exercise. I would tell a patient that after a few months of this regimen we could check the cholesterol level again and if it went down a substantial amount, I would feel comfortable taking them off the medication as long as they continued with the diet and exercise lifestyle. I have found that simply listening to a patient can help you create a better plan that incorporates their wishes while also providing the best possible medical care.

Kathleen

Nov 9, 2019Nov 9, 2019 at 9:04pm

Kathleen & Dr Storms,

I agree with listening to what the patient’s idea is in getting the Cholesterol level down. It is important to allow the patient to manage their health independently, even if it means remaining in a supportive role and as a voice of reason if the patient wishes to try the herbal medicine instead of Zocor. We could even ask that they also change their eating habits at home to include better nutrition (low cholesterol dieting) as a way to decrease their cholesterol levels. These are great ways to start in the provider – patient relationship and gain the trust of the patient by ensuring that we are capable of supporting their right to make healthcare choices, manage and maintain their health.

-Kelda

Collapse Subdiscussion Kenneth Steier

Kenneth Steier

Nov 7, 2019Nov 7, 2019 at 12:21am

Hello Dr. Storm and classmates,

In this week’s discussion posts I am looking at the four (4) positions that are categorized as APN positions. The four APN positions that I am looking at are the CNP, CNS, CRNA and CNM positions. I will talk about the work environment, level of accountability, patient population, salary and scope of practice for each of the APN roles in the state of New Jersey where I live. I will then give personal Pros/Cons for each role. I will give a rationale for why I have chosen the CNP advanced practice role versus any of the other APN roles. I will then also talk about plans for clinical practice after graduation. Lastly, I will talk about changes in opinion of NP practice as it relates to what I have learned from researching the different APN roles in New Jersey.

Work environments of APN roles:

Certified Nurse Practitioners (CNP’s):

New Jersey CNP’s practice in a wide variety of work environments in the carrying out of their healthcare responsibilities. These include the average/everyday healthcare settings that are clinics, office practices, managed care organizations, hospitals, college campuses, urban community health centers, long term care facilities, ambulatory care clinics, correctional facilities, homes and worksite employee health centers. These CNP positions can be in the rural areas, as well as in urban areas. Some alternative areas of employment where CNP’s are employed are in healthcare technology companies, healthcare research companies and teaching in schools as professors.

Certified Nurse Specialists (CNS):

New Jersey CNS’s practice in a wide variety of work environments in the carrying out of their healthcare responsibilities. Most CNS’s work in inpatient hospital settings and then the rest work in clinical settings ranging from home health care to public health centers.

Certified Registered Nurse Anesthetist (CRNA):

New Jersey CRNA’s practice in a wide variety of work environments in the carrying out of their healthcare responsibilities. “According to the American Association of Nurse Anesthetists, CRNAs deliver anesthesia in every medical setting where it is required, including operating rooms, outpatient clinics, dental offices, and pain management clinics; as well as offices of ophthalmologists, podiatrists, and cosmetic surgeons” (Certified Registered Nurse Anesthetist (CRNA), 2019).

Certified Nurse Midwife (CNM):

New Jersey CNM’s practice in a wide variety of work environments in the carrying out of their healthcare responsibilities. CNM’s can practice in hospitals, physician’s offices, home healthcare providers, community health clinics, military bases and hospitals as well as at-home birth services.

Level of Accountability:

Certified Nurse Practitioners (CNP’s):

Nurse Practitioners are leaders in the healthcare community and are responsible for delivering high quality health care to the communities that they serve in the state of New Jersey. NP accountability is consistent with an ethical code of conduct, national certification, periodic peer review, clinical outcome evaluation, and evidence of continued professional development.

Certified Nurse Specialist (CNS):

“Nurses with a CNS designation commonly hold leadership roles, influence policy decisions, develop patient treatment plans, and educate patients and colleagues” (Clinical Nurse Specialist (CNS), 2019). Training in the masters educated fields of CNS has led to skills and providers that are easily able to transition into positions of authority and leadership. They are responsible to continue to advance their practice and do so in an ethical manner, to get state BON certification, assess clinical outcome evaluation and continue to develop and advance their knowledge in their field of care.

Certified Registered Nurse Anesthetist (CNRA):

“Certified Registered Nurse Anesthetists enjoy a unique level of respect within the medical community thanks to their ability to administer anesthesia in the same manner and in identical situations as physicians who specialize as anesthesiologists” (Certified Registered Nurse Anesthetist (CRNA)). The accountability for CRNA’s is great as they are required to continue to expand their knowledge and use of different medications that is used as anesthesia. They must keep up to date and continue learning new medications that are used. The CNRA is accountable to the patients they see, surgeons they work with, anesthesiologists that are supervising them and to use the anesthesia medications that they are responsible for in an ethical manner.

Certified Nurse Midwife (CNM):

“The international confederation of Midwives defines a midwife as a “responsible and accountable” person who works in partnership with women to provide them with the “necessary support, care and advice during pregnancy labor and the postpartum period” (How to Become a Certified Nurse Midwife (CNM), 2019). The midwife is accountable in that they are responsible for knowing about the birthing process and how to care for the mother, baby, reproductive health, as well as puberty and menopause care and consultation and education for patients needs. They are also needing to renew their CNM licenses and provide care that helps to make the birthing process and other care the best possible for all involved, mother and child.

Patient Population:

Certified Nurse Practitioners (CNP’s):

CNP’s work with a wide variety of patient populations. They can work in family care (anywhere from newborn to older adults), neonatal care, pediatrics (from newborns up to 21-year-old patients), adult (adolescents to older adults), women’s health, gerontological care and psychiatric/mental health. In addition to these options there are specializations from primary and acute care, diabetes management, oncology, palliative care and emergency medicine.

Certified Nurse Specialist (CNS):

“Clinical nurse specialists oversee every aspect of their patient’s experience” (Clinical Nurse Specialist (CNS), 2019). Clinical Nurse specialists can work with pediatrics, critical care, cardiology, psychiatry/behavioral health, hospice, community health and gerontology.

Certified Registered Nurse Anesthetist (CRNA):

Patient population for a CRNA could be any patient requiring a surgical procedure and others that need to have anesthesia administered. This client population could literally be anyone from birth all the way through to the later years in life. “Certified Registered Nurse Anesthetists deliver anesthesia to more than 32 million patients in the United States each year and are the primary providers of anesthesia in medically underserved areas around the country” (Certified Registered Nurse Anesthetist (CRNA), 2019).

Certified Nurse Midwife (CNM):

Nurse Midwives patient population consists of many different facets of the mother/baby scenario. These different aspects of care can include: Acute care for women; Women primary care; Neonatal care; Antepartum, Intrapartum and Postpartum care/issues; Non-surgical gynecological care; Women’s Health; Childbirth and Delivery; Reproductive Health; Puberty and Menopause; Consultation and educational services.

Salary:

Certified Nurse Practitioners (CNP’s):

Median Salary in New Jersey for CNP’s is $117,630 in 2017.

Certified Nurse Specialist (CNS):

Median Salary in New Jersey for CNS’s is $90,000 in 2017.

Certified Nurse Anesthetist (CRNA):

Median Salary in New Jersey for CRNA’s is $180,000 in 2017.

Certified Nurse Midwife (CNM):

Median Salary in New Jersey for CNM’s is $111,600 in 2017.

Scope of Practice:

Certified Nurse Practitioners (CNP’s):

Nurse practitioners assess, diagnose, treat and manage acute episodic and chronic illnesses. They are involved in health promotion and disease prevention. Certified Nurse Practitioners order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmaceutical agents and non-pharmacologic therapies, as well as teach and counsel patients. Nurse Practitioners are responsible for a wide range of health care services to individuals, families and communities.

In New Jersey Nurse Practitioner are considered Primary Care Providers. “Primary care provider includes the following licensed individuals: physicians, physician assistants, advanced practice nurses and nurse midwives whose professional practice involves the provision of primary care, including internal medicine, family medicine, geriatric care, pediatric care or obstetrical/gynecological care” (New Jersey State Profile, 2019). NP’s have independence of practice in terms of seeing patients on their own, but they must have a relationship with a physician to do oversight of the care/prescriptions that is provided. In that sense, the state of New Jersey is a collaborative care state which requires that NP’s have a joint-protocol agreement with a supervising physician for the right of prescribing medications/equipment.

Certified Nurse Specialists (CNS):

Nurse Specialists work directly with patients, they implement treatment plans to resolve or mitigate medical or psychiatric issues. They also perform a larger role inside of healthcare facilities, they are involved in shaping the healthcare system by serving as mentors to fellow nurses and by systematically applying observations of direct patient care to research. They are always trying to improve the quality of care that is administered to patients by watching how care is given and educating nurse peers on how to improve upon their care so that that care is constantly evolving/improving. In New Jersey CNS nurses must have a joint protocol set up with a supervising physician, so that they can prescribe medications.

Certified Registered Nurse Anesthetist (CRNA):

Certified Registered Nurse Anesthetist makes a complete assessment of a patient’s health condition and previous reactions to anesthesia. CRNA’s are responsible for identifying possible risks during a medical procedure, conveying those risks to patients, giving anesthesia/pain medications throughout the procedure and managing/monitoring patients’ condition throughout the procedure and recovery period. In New Jersey CRNA’s can give medications to patients during a procedure, but do not have prescribing rights with or without physician supervision.

Certified Nurse Midwife (CNM):

“The American Pregnancy Association notes that the model of care administered by nurse midwives is based on the fact that pregnancy and birth are normal life processes” (How to Become a Certified Nurse Midwife (CNM), 2019). The midwife establishes and promotes a compassionate partnership with the woman and her family, and acknowledging each woman’s life experiences and knowledge, which may include recognizing individualized methods of care and healing. Midwives monitors the physical, psychological and social well-being of the woman throughout their childbearing cycle. They are there to provide education, counseling, prenatal care, postpartum support and continuous hands-on assistance to the mother. They are also involved in minimizing any interventions and they identify those patients that need obstetrical care.

Personal Pros/Cons for each role:

Nurse Practitioner:

Pros Cons

Making a huge difference in patient lives. Sad situations that you will be a part of
Have options, or different career paths to choose Stress of being a Nurse Practitioner
Diversity and interesting factors to job Patients can be hard to deal with
Autonomy of care Emotional strain

Certified Nurse Specialist:

Pros Cons

Career Options Difficult conditions
Choosing a specialty Difficulty with co-workers
Good Pay Working long days
Nursing is a trusted profession Burnout of Nurses

Certified Registered Nurse Anesthetist:

Pros Cons

Pay Long/unpredictable shifts
Autonomy Competition
Helping others Difficulty in getting through school
Professional Respect Debt paid to get degree

Certified Nurse Midwife:

Pros Cons

Meeting new mothers Getting calls all hours of day/night
Helping with new mothers/baby Hospital delivery privilege restrictions
Seeing Newborns be born Long hours put in by Midwife
New deliveries Strain practice puts on relationships

Plans for Practice after graduation:

I want to settle down after graduating from Nurse Practitioner school and find my niche in one of the many different fields that are available as an NP. I believe that I may start as a Family or Pediatric NP and then expand my knowledge and find out which patient population I enjoy treating the most. I am looking forward to the challenge and expansion of knowledge that we are all soon to be experiencing. I want to take one thing at a time and then investigate what the major options are for the field of Nurse Practitioners now and going into the future.

What I have learned:

The field of Advanced Nurse Practitioner has many different specialties, and all have their own pluses and minuses. I think that this taught me that all the APN positions are very well respected and are all well paid. My respect for all the APN specialty tracts has grown and I appreciate all of them more now that I have completed this assignment. The Nurse Practitioner tract seems to have the most available options and I believe that I have chosen the field that I currently feel the most comfortable with.

References

Certified Registered Nurse Anesthetist (CRNA). (2019). Retrieved from http://www.graduatenursingedu.org

Clinical Nurse Specialist (CNS). (2019). Retrieved from http://www.graduatenursingedu.org

Clinical Nurse Specialist (CNS). (2019). Retrieved from http://www.nursing.org/careers/clinical-Nurse/

How to Become a Nurse Practitioner (NP). (2019). Retrieved from http://www.rntobsn.org/careers/nurse-practitioners/

How to become a Nurse Practitioner | What is a Nurse Practitioner? (2019). Retrieved from http://www.graduatenursingedu.org

New Jersey State Profile. (2019). Retrieved from http://scopeofpracticepolicy.org/states/nj/

Pages – New Jersey Board of Nursing. (2019, February 7). Retrieved from http://www.njconsumeraffairs.gov/nur/Pages/default.aspx

Society of Psychiatric APNs – Guidelines for Collaborative Practice. (2019). Retrieved from https://www.psychapn.org/practice-guidelines (Links to an external site.)

How to Become a Certified Nurse Midwife (CNM). (2019). Retrieved from http://www.rntobsn.org/careers/nurse-midwives/

Collapse Subdiscussion Kenneth Steier

Kenneth Steier

Nov 7, 2019Nov 7, 2019 at 12:38am

Rationale for Why I chose Nurse Practitioner role over other roles:

I believe that this CNP tract will be the most beneficial option. I think that the CNP tract has the most options, or career paths that are available to the Nurse after completion of the program. The autonomy of care, as well as the ability to collaborate in the state of New Jersey with Physicians will be a welcome benefit. I am a nurse currently on a Med-Surge floor and find myself knowing what the physicians are ordering and for what diseases. There will be a greater feeling of helping patients get better if I am actively the one that is seeing the patient and ordering medications/procedures/diagnostics instead of just going about handing out the treatments that are ordered as a nurse. I believe that I can play a more active role in health promotion and disease prevention by doing preventative checkups with patients also as a NP. I will feel that more people are being helped by staying out of hospitals because they are preventing illness and chronic disease before it can appear as a symptom that needs hospital intervention to help heal/repair.

Collapse Subdiscussion Shaniya Tripp

Shaniya Tripp

Nov 7, 2019Nov 7, 2019 at 4:30pm

Kenneth,

Health promotion and disease prevention are also two of the main driving forces for me choosing the clinical nurse practitioner (CNP), advanced practice registered nurse (APRN) role. Researching for this week’s assignment helped to solidify my decision because I realized just how important this role is to the generalized population. I too, would like to play a more active role in health promotion and disease prevention. Being a transplant nurse is rewarding as I navigate through the journey with a post-operative patient, but it can also be disheartening losing a patient who died waiting for a transplant or watching my patient suffer dealing with the complications associated with organ failure. I have seen patients as young as thirty years old, who require a kidney transplant due to uncontrolled diabetes causing end-stage renal disease. As you mentioned, the goal is to keep patients out of the hospital setting. I would like to contribute my time and effort into preventing a need for a transplant. As a CNP, some ideas I would like to pursue will be to educate on healthy eating habits, manage patients with both Type 1 and Type 2 diabetes, educate and participate in safe needle exchange programs, promote exercise to combat the rising incidence of obesity, and more. Caring for this population has given me the motivation to want to make a difference before it is too late, and that is why I have been driven toward this specific APRN role. It is great to see that you also share these ideas on the roles and responsibilities of a CNP. With more of our colleagues advancing their careers to become CNP’s, it is the hope that we can focus our careers on both health promotion and disease prevention to help prevent complex disease processes and hospital admissions. Great post!

Shaniya

Nov 8, 2019Nov 8, 2019 at 8:36am

Kenneth, the NP role is a great opportunity to provide the preventive care that you want to. Health promotion is such a huge part of the care we provide and so necessary to help our patients get healthy and stay healthy. Something you want to look into is what local resources you have for health promotion and disease prevention. For example, our hospital offers Coronary Artery Calcium scoring. This is a quick CT scan that looks at coronary calcium buildup. It catches heart attacks before they happen. I had a patient that we ordered one of these studies on a few weeks ago. He was asymptomatic, 67 years old, and cholesterol was PRISTINE! He had no medical problems. You’d think low risk, right? Well, any of my patients over the age of 55 get offered this scan. In this patient’s case, he agreed to it. Thinking it would be normal, but just to be safe, he went and did the scan. His score was 2050 by Agatson criteria. I had him follow up, referred to cardiology, and the same week he had quadruple bypass! This man’s life was saved by a screening study. Insurance does not cover the scan, it costs $140. I tell patients $140 is a lot cheaper than a heart attack or stroke and they never give me push back on this. This is just an example of preventive and promotional care we provide as NPs. Check out what screening tests are performed in your area and consider offering these to your patients.

Collapse Subdiscussion Melissa Stone

Melissa Stone

Nov 8, 2019Nov 8, 2019 at 11:17am

Dr. Storms,

Thanks for your information on Coronary Artery Calcium scoring as I have never heard of this before! It is amazing how far technology has come in healthcare and how convenient it is. It sounds like this testing is truly saving lives, and only at $140. I think the problem in many communities including my own is that people are not well educated about their health issues so getting them to follow through with the testing is huge. Educating my patients is something that I am excited and passionate about doing because they truly need it! My unit does many CABG surgeries every month and unfortunately, whether it be cost, motivation, lack of caring, or education we see many of these patients back in again because they are noncompliant. My hope is to be able to change patients lives and be someone that they are not afraid of explain their concerns to. Being able to spend that time with patients and let them know that compliance and understanding their disease process is crucial! My hospital does offer free cholesterol, blood pressure and glucose screening every month, so I am curious as to how many people take advantage of this.

Nov 10, 2019Nov 10, 2019 at 3:58pm

Dr Storms,

Phenomenal. Congratulations and I am glad this turned out well for the patient. Good advice. Thanks for sharing this.

– Kelda

Collapse Subdiscussion Juliana Onalaja

Juliana Onalaja

Nov 10, 2019Nov 10, 2019 at 8:41pm

Dr. Storm,

As a HIV Nurse Case manager I work closely with the Advance Practice nurse (APRN) Nurse practitioners who work primarily in the HIV clinic and inpatient hospital to identify patients who are newly diagnosed HIV to be screened specifically for Syphilis. According to U.S. Department of Health and Human services Syphilis is associated with an increased risk of sexual acquisition and transmission of HIV. In recent years, there has been a resurgence of the disease among men across the United States and in Western Europe. Although coexistent HIV infection (particularly in the advanced stages) may modify the diagnosis, natural history, or management of Treponema palladium infection , the principles of syphilis management remain the same for person with and without coexistent HIV infection( Guidelines for the prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV, 2015). Once the new HIV diagnosed patient is identified and tested for Syphilis is positive, we try to get the patient to come for extra educational course, schedule appointments for there three injections of penicillin, set up same day or within a couple of days appointments as oppose to our appointment in two weeks for HIV (along with other comorbidities) only appt. We have found that the show up rates for appointments, and taking HIV medications were better. Our patients were less likely to continue sex without condoms. Also reoccurrence rates or new sexually transmitted diseases were lower among our newly diagnosed HIV/Syphilis patients after a year of monitoring.

Thanks,

Juliana

References

(2015, December 17). Guidelines for the prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Retrieved from http://www.Aidsinfo.nih.gov NUR 510 Week 2 discussion – Leadership and Role of the Advanced Practice Nurse

Collapse Subdiscussion Juliana Onalaja

Juliana Onalaja

Nov 10, 2019Nov 10, 2019 at 8:58pm

Hi Kenneth,

I believe you summed it up for me when you stated doing the Nurse Practitioner tract will be the most beneficial. Not only do I work as an HIV CM but continue to do Prn work as a Medical Surgical nurse and this allows me to keep up with my clinical skills and knowledge about ongoing health problems. I find being knowledgeable in many areas will help solidify my role as a Family Nurse Practitioner who will be able to relate and navigate all types of health issues my patients will face. May it be preventative to curative measures I will be able to comfortably connect the pieces to create a plan of care my patients will understand and follow. As a Nurse Practitioner, I will be instrumental charting the path of recovery, cure, or ongoing healthy patterns for the client to easily follow. Preventative health care has been stance I strongly believe in since my days as a research technologist on the Women’s health initiative study over 20 years ago. What you don’t know might not kill you, but what you do know can start the path of delaying or preventing a serious problem that could eventually kill you. I believe in the latter because ultimately the benefits of prevention due to knowledge is better for everyone.

Thanks,

Juliana

Collapse Subdiscussion Juliana Onalaja

Juliana Onalaja

Nov 9, 2019Nov 9, 2019 at 2:35pm